Inspection Reports for Cadia Rehabilitation Pike Creek

An announced follow-up and complaint survey was conducted at the facility from June 16 through June 17, 2025.

The facility was found to be in substantial compliance with applicable regulations. No deficiencies were identified at the time of the survey.

The survey was complaint-related and follow-up in nature. The facility was found to be in substantial compliance.

A Recertification and Complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Delaware, Department of Health and Social Services, Division of Health Care Quality from 04/14/25 to 04/18/25.

The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified related to visitation rights, safe environment, abuse investigation, transfer/discharge notices, care planning, quality of care, medication errors, food service, and pest control among others.

The complaint investigation was substantiated as the facility was found not in substantial compliance with multiple regulatory requirements including visitation rights, abuse investigation, and quality of care.

An unannounced complaint survey was conducted at the facility from February 11, 2025 through February 17, 2025 to investigate complaints and assess compliance with regulatory requirements.

The facility was found deficient in multiple areas including failure to ensure residents received proper post-fall assessments and monitoring, respiratory and tracheostomy care, and laboratory services per physician orders. Deficiencies were based on observations, interviews, and record reviews of residents' clinical records and facility documentation.

The visit was complaint-related, triggered by allegations concerning resident care. The deficiencies were substantiated based on the investigation.

A Recertification and Complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Delaware, Department of Health and Social Services, Division of Health Care Quality from 03/18/24 to 03/21/24.

The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified in areas including safe environment, accuracy of assessments, care plan timing and revision, nutrition/hydration status maintenance, pain management, trauma informed care, and pharmacy services.

An unannounced complaint survey was conducted at the facility from January 29, 2024 through January 30, 2024.

The facility was found to be in substantial compliance with 42 CFR Part 483 Subpart B Requirements for Long Term Care Facilities. No deficiencies were identified during the survey.

The survey was complaint-related and included observations, interviews, and review of residents' clinical records. No deficiencies were identified, indicating substantial compliance.

An unannounced Complaint Survey was conducted at the facility from October 12, 2023 through October 17, 2023 to investigate complaints and assess compliance with regulatory requirements.

The survey identified multiple deficiencies related to notification of changes in resident condition, medication administration, quality of care, physician visits, resident records, and transport policies. Specific issues included failure to notify providers of significant changes, medication errors, inadequate implementation of care plans, and improper documentation.

The visit was an unannounced complaint survey conducted from October 12 to October 17, 2023. The deficiencies were based on observations, interviews, clinical record reviews, and facility documentation. The facility census on the first day was 166 residents, with a survey sample size of 19 residents.

An unannounced Follow-Up Survey for the Annual and Complaint Survey ending February 23, 2023, was conducted by the State of Delaware Division of Health Care Quality Office of Long Term Care Residents Protection from April 12, 2023 through April 13, 2023.

The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care as of March 24, 2023. No deficiencies were identified at the time of the survey.

An unannounced Annual and Complaint Survey was conducted at the facility from February 13, 2023 through February 23, 2023 to assess compliance with state and federal regulations for skilled and intermediate care nursing facilities.

The facility failed to meet the minimum staffing requirement of 3.28 hours of direct care per resident per day for three days and failed to ensure reasonable accommodations, proper Medicaid/Medicare coverage notifications, comprehensive care plans, proper bowel and bladder care, medication storage and labeling, infection control, and other regulatory requirements. A norovirus outbreak was identified and the facility failed to fully implement infection control measures.

An unannounced COVID-19 Focused Infection Control and complaint survey was conducted at the facility from August 17, 2021 through August 18, 2021.

The facility was found to be in compliance with COVID-19 infection control regulations but failed to maintain the minimum nursing staffing level of 3.28 hours of direct care per resident per day for two days reviewed. Staffing shortages were due to COVID-19 outbreaks affecting nursing staff.

The survey was complaint triggered and included a COVID-19 Focused Infection Control component. The complaint was substantiated by findings related to staffing shortages during a COVID outbreak.

A COVID-19 Focused Infection Control Survey and Complaint Survey was conducted by the State of Delaware Division of Health Care Quality from February 17, 2021 through March 1, 2021.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented the CMS and CDC recommended practices to prepare for COVID-19. No deficiencies were identified at the time of the survey.

The survey included a complaint investigation component; however, no deficiencies were identified.

An unannounced COVID-19 Focused Infection Control and Complaint Survey was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection from January 5, 2021 to January 11, 2021.

The facility failed to ensure that one of three sampled residents received treatment and care in accordance with professional standards for post-fall assessment and monitoring, resulting in a three-day delay in reporting a fall. Additionally, the facility failed to ensure appropriate use of transfer devices to prevent accidents for one resident.

The survey was complaint-related, focusing on infection control and specific allegations regarding fall reporting and transfer device use. The findings indicate substantiated deficiencies related to delayed fall reporting and improper use of transfer devices.