Inspection Reports for
Cadia Rehabilitation Pike Creek

The complaint investigation included allegations of visitation restriction, failure to maintain a homelike environment, inadequate injury investigation, delayed treatment for change in condition, lack of wound care, and insufficient supervision leading to falls and injuries.

The facility was found to have multiple deficiencies including restricting family visitation rights, failing to maintain a homelike environment by improper disposal of soiled briefs, inadequate investigation of an injury of unknown origin, failure to timely identify and treat a resident's change in condition resulting in immediate jeopardy, failure to provide wound care upon admission, and inadequate supervision leading to resident falls and injuries.

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.

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 facility failed to ensure proper post-fall assessments and monitoring for residents R1 and R3, failed to provide consistent respiratory care including tracheostomy and respiratory mouth care for five residents, and failed to obtain laboratory results for antiseizure medications as ordered for residents R1 and R3.

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

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 facility failed to provide a homelike environment for five of 49 sampled residents, with issues including broken and stained privacy curtains, ceiling stains, unclean rooms with trash and dust, and delayed maintenance responses.

The facility failed to maintain a safe, clean, and homelike environment for residents, accurately code assessments, provide advance notice for care plan meetings, obtain timely reweighs after significant weight loss, ensure timely delivery and administration of pain medications, and provide trauma-informed, culturally competent care. Several residents experienced environmental issues, inaccurate assessments, missed care plan participation, significant weight loss without timely reweigh, unresolved pain due to medication delivery issues, and inadequate trauma care planning.

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.

The complaint investigation included issues such as failure to notify providers of significant changes in resident condition, medication administration errors, inadequate transportation arrangements, failure to resume critical medications post-procedure, and inaccurate clinical documentation by providers.

The facility was found deficient in multiple areas including failure to notify providers of significant resident condition changes, medication administration errors, inadequate transportation policies, failure to resume anticoagulant medication post-procedure leading to resident death, and inaccurate clinical documentation by providers.

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.

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 facility failed to ensure that active physician orders for two residents with GJ tubes (R54 and R80) clearly specified which port (gastric or jejunal) to use for medication administration, tube feedings, residual checks, and tube placement. Interviews with nursing and medical staff confirmed a lack of clarity and knowledge regarding the correct port to use.

The facility was found deficient in multiple areas including failure to ensure call bells were within reach, failure to obtain required beneficiary protection signatures, incomplete care plans, inadequate interdisciplinary team participation in care planning, improper catheter care, medication storage and labeling issues, kitchen handwashing station maintenance, and significant infection control failures during a norovirus outbreak including lack of contact precautions, inadequate staff education, and improper wound care.

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.

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.

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-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.

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 facility was found to have multiple deficiencies including failure to accommodate resident needs, failure to notify physicians of treatment refusals, inadequate care planning, failure to meet professional standards of quality, medication errors, insufficient staffing, infection control lapses, and failure to provide timely diagnostic and dental services.