Inspection Report Summary
The most recent inspection on August 13, 2025 identified multiple deficiencies related to resident rights, care planning, pain management, nurse staffing, pharmacy and radiology services, food safety, and pest control. Earlier inspections showed a pattern of similar issues including staffing shortages, medication errors, inadequate care planning, and failure to meet training and screening requirements. A notable substantiated complaint involved a medication error causing hospitalization and ICU admission, with the responsible nurse suspended and additional deficiencies found in staff training and reporting. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history indicates ongoing challenges with regulatory compliance, with deficiencies persisting over time rather than clear improvement.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
43.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
392% worse than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
156 residents
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 156
Deficiencies: 14
Date: Aug 13, 2025
Visit Reason
An unannounced Annual and Complaint survey was conducted at Pike Creek Nursing and Rehabilitation Center from August 4, 2025 through August 13, 2025 to assess compliance with regulatory requirements.
Complaint Details
The survey included complaint investigations related to resident rights, grievances, abuse/neglect allegations, and quality of care. Several complaints were substantiated as evidenced by the deficiencies cited.
Findings
The survey identified multiple deficiencies related to resident rights, grievance procedures, reporting of alleged violations, discharge processes, comprehensive care plans, pain management, nurse staffing, pharmacy services, radiology services, food safety, and pest control. Several deficiencies were noted as past events and the facility was unable to retroactively correct them.
Deficiencies (14)
Resident Rights/Exercise of Rights - Facility failed to promote resident dignity and respect during dining and entering resident rooms without permission.
Grievances - Facility failed to ensure prompt resolution and proper documentation of grievances.
Reporting of Alleged Violations - Facility failed to report an incident involving a resident to the State Agency within required timeframes.
Discharge Process - Facility failed to provide timely and adequate notice of transfer or discharge to residents and representatives.
Develop/Implement Comprehensive Care Plan - Facility failed to develop and implement comprehensive person-centered care plans for residents.
Care Plan Timing and Revision - Facility failed to update care plans timely for residents with newly identified needs.
Quality of Care - Facility failed to provide care in accordance with professional standards for residents receiving hospice services.
Pain Management - Facility failed to ensure non-pharmacological interventions were attempted prior to using pain medication for residents.
Posted Nurse Staffing Information - Facility failed to post nurse staffing data daily as required.
Pharmacy Services - Facility failed to ensure accurate medication administration records and proper disposal of controlled substances.
Radiology/Diagnostic Services - Facility failed to promptly notify ordering physicians of radiology results and follow up on abnormal findings.
Drug Regimen is Free from Unnecessary Drugs - Facility failed to ensure residents' drug regimens were free from unnecessary drugs.
Food Safety Requirements - Facility failed to maintain proper food storage and handling practices, including pest control.
Maintains Effective Pest Control Program - Facility failed to ensure kitchen dry food storage room was free of pests.
Report Facts
Facility census: 156
Investigate sample: 37
Deficiencies cited: 13
Date survey completed: Aug 13, 2025
Plan of correction completion dates: Various dates mostly 2025-09-26 for corrective actions
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Aug 13, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident rights, care planning, treatment, and staffing.
Findings
The facility was found deficient in promoting resident dignity, developing comprehensive care plans, ensuring appropriate treatment and care according to orders and preferences, and posting nurse staffing information daily. Specific issues included failure to provide drinkware during meals, entering resident rooms without permission, incomplete care plans for residents with medical needs, failure to schedule follow-up appointments, lack of hospice care plan integration, and failure to post daily nurse staffing information.
Deficiencies (4)
Failure to promote resident dignity as evidenced by observations during dining and entering resident rooms without permission.
Failure to develop a comprehensive person-centered care plan for residents that addressed medical needs.
Failure to ensure residents received care and services in accordance with professional standards, care plans, and physician orders, including failure to schedule vascular surgery follow-up and collaborate with hospice.
Failure to post nurse staffing information daily including resident census and total nursing hours worked per shift.
Report Facts
Residents reviewed for care plans: 37
Residents sampled for investigation: 37
Days of nurse staffing posting observed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E3 | Director of Nursing (DON) | Interviewed regarding staff expectations for entering resident rooms and care plan deficiencies |
| E1 | Nursing Home Administrator (NHA) | Interviewed and participated in exit conference regarding findings |
| E2 | Registered Dietitian Consultant (RDCS) | Participated in exit conference regarding findings |
| E4 | Assistant Director of Nursing (ADON) | Interviewed regarding care plan deficiencies and participated in exit conference |
| E12 | Licensed Practical Nurse (LPN) | Observed entering resident room without permission |
| E13 | Licensed Practical Nurse (LPN) | Observed entering resident room without permission |
| E14 | Housekeeping Aide (HA) | Observed entering resident rooms without permission |
| E15 | Certified Nursing Assistant (CNA) | Observed entering resident room without knocking |
| E16 | Housekeeping Aide (HA) | Observed entering resident rooms without permission |
| E17 | Contracted Nurse Practitioner (NP) | Observed entering resident room without knocking |
| E18 | Housekeeping Aide (HA) | Observed entering resident room after knocking and announcing housekeeping |
| E8 | Unit Clerk | Tasked with scheduling vascular surgery follow-up appointment but failed to do so |
| E10 | Licensed Social Worker (LSW) | Interviewed regarding hospice binder and care plan |
| E32 | Licensed Practical Nurse (LPN) | Interviewed regarding access to hospice care plan |
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 0
Date: Feb 28, 2025
Visit Reason
An unannounced complaint survey was conducted at the facility to investigate concerns raised.
Complaint Details
The complaint investigation was unannounced and conducted from February 26 through February 28, 2025. No deficiencies were found and no deficient practice was identified.
Findings
No deficient practice was identified during the complaint investigation survey.
Report Facts
Survey sample residents: 17
Inspection Report
Annual Inspection
Census: 169
Deficiencies: 22
Date: Sep 10, 2024
Visit Reason
An unannounced Annual, Complaint and Extended survey was conducted from July 29, 2024 through September 10, 2024 to assess compliance with federal and state regulations for Pike Creek Nursing & Rehabilitation Center.
Findings
The survey identified multiple deficiencies across various areas including mandatory drug testing, dementia training, tuberculosis testing, medication errors, resident rights, staffing, criminal background checks, abuse prevention, care planning, and nursing services. The facility failed to meet several regulatory requirements as evidenced by detailed findings and corrective action plans.
Deficiencies (22)
Mandatory drug testing was not completed for certain employees as required.
Mandatory dementia training was not completed for sampled employees.
Mandatory tuberculosis testing was not completed for certain employees.
Significant medication errors were identified including failure to report within required timeframes.
Resident rights notices were not properly posted and admissions staff failed to provide required information.
Staffing levels failed to meet minimum required direct care hours per resident per day.
Criminal background checks were not completed timely for certain staff.
Mandatory drug screening results were not obtained for certain employees.
Significant medication errors and omissions were identified, including failure to report and educate staff.
Resident privacy and dignity were compromised due to improper handling of catheter bags.
Failure to protect residents from abuse, neglect, and mistreatment including verbal and emotional abuse.
Failure to investigate and report allegations of abuse timely and appropriately.
Failure to provide adequate care for residents with pressure ulcers and skin integrity issues.
Failure to provide adequate nursing care and assessments for residents with incontinence and mobility issues.
Failure to provide adequate pain management and medication administration documentation.
Failure to provide adequate nursing staff training and competency validation.
Failure to maintain adequate nursing care plans and assessments for residents.
Failure to provide adequate pain management and medication administration documentation.
Failure to provide safe and sanitary care for residents with urinary catheters.
Failure to provide adequate respiratory care and oxygen therapy.
Failure to provide adequate pain management and medication administration documentation.
Failure to provide adequate nursing services and medication management.
Report Facts
Residents in investigative sample: 64
Residents in census: 169
Date survey completed: Sep 10, 2024
Date of completion for corrections: Oct 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian Loehman | NHA | Named as provider signing the report |
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: Sep 10, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a significant medication error involving a resident who was administered the wrong medications, resulting in hospitalization and ICU admission.
Complaint Details
The complaint investigation substantiated a medication error where a nurse administered medications prescribed for another resident, resulting in the affected resident becoming hypotensive and hypoglycemic, requiring emergency transfer to hospital ICU. The nurse was suspended pending investigation. The facility failed to immediately report the error and failed to educate nursing staff adequately on medication administration.
Findings
The facility failed to properly identify residents prior to medication administration, resulting in a medication error that caused hypoglycemia and hypotension in a resident. The facility also failed to immediately report the error, failed to suspend the responsible nurse, and failed to provide adequate education and competency training to nursing staff. Additional deficiencies were found related to dental services, food and nutrition, resident records, COVID-19 immunization, communication training, abuse prevention training, and staff training compliance.
Deficiencies (10)
Failure to dual identify the resident prior to medication administration resulting in medication error and hospitalization.
Failure to provide routine and emergency dental services to residents.
Failure to provide food that meets residents' nutritional needs and preferences.
Failure to maintain resident records accurately and confidentially.
Failure to provide required COVID-19 immunizations and education.
Failure to provide effective communication training for direct care staff.
Failure to provide abuse, neglect, and exploitation training to staff.
Failure to provide required in-service training for nurse aides.
Failure to provide compliance and ethics training for staff.
Failure to provide behavioral health training for nursing staff.
Report Facts
Date survey completed: Sep 10, 2024
Date of completion: Nov 11, 2024
Number of residents sampled for medical record review: 50
Number of nursing staff files reviewed: 5
Number of employees files audited: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E43 | Registered Nurse (RN) | Named in medication error finding and suspension pending investigation |
| E44 | House Supervisor | Involved in medication error incident and interviews |
| E45 | Certified Occupational Therapy Assistant (COTA) | Provided statements regarding medication error incident |
| E36 | Unit Manager (UM)/On call nurse | Interviewed regarding medication error and hospital transfer |
| E3 | Administrator on Duty (ADON) | Involved in investigation and interviews related to medication error |
| E1 | Nursing Home Administrator (NHA) | Interviewed regarding medication error and facility status |
| E2 | Director of Nursing (DON) | Interviewed regarding medication error and facility education |
| E10 | Vice President of Operations (VPO) | Interviewed regarding medication error and facility education |
| E48 | Staff Educator | Interviewed regarding staff training and education |
| E57 | Registered Nurse (RN) | Staff training records reviewed |
| E58 | Licensed Practical Nurse (LPN) | Staff training records reviewed |
Inspection Report
Complaint Investigation
Deficiencies: 18
Date: Sep 10, 2024
Visit Reason
The inspection was conducted based on complaint investigations and review of incidents involving resident care, medication errors, abuse allegations, and quality of care concerns.
Complaint Details
The complaint investigation included multiple allegations such as failure to notify family of falls, failure to consult physicians on medication refusals, unresolved grievances, verbal and emotional abuse, delayed reporting of abuse, inadequate care planning, failure to protect residents from accidents, medication errors, lack of staff competency validation, poor food quality, inaccurate medical records, and lack of mandatory staff training. Some incidents resulted in immediate jeopardy to resident health and safety.
Findings
The facility was found deficient in multiple areas including failure to notify family of resident falls, failure to consult physicians on medication refusals, unresolved grievances, verbal and emotional abuse, delayed reporting of abuse allegations, inadequate care planning, failure to protect residents from accidents, unsafe medication administration, lack of nursing staff competency validation, improper medication storage, poor food quality, inaccurate medical records, lack of mandatory staff training, and failure to conduct quality assurance activities.
Deficiencies (18)
Failed to inform resident's representative of a fall.
Failed to consult physician of resident's repeated medication refusals.
Failed to resolve grievances in a timely manner.
Failed to protect resident from verbal and emotional abuse.
Failed to timely report suspected abuse and failed to immediately report sexual abuse allegation.
Failed to develop and revise care plans timely and adequately.
Failed to provide care and assistance for activities of daily living.
Failed to ensure adequate supervision and assistive devices to prevent accidents.
Failed to ensure nursing staff had appropriate competencies and skills validated.
Failed to ensure medications were stored and labeled properly.
Failed to ensure residents were free from significant medication errors.
Failed to ensure food was palatable and served at safe and appetizing temperatures.
Failed to maintain accurate medical records.
Failed to ensure mandatory effective communication training for all direct care staff.
Failed to conduct quality assurance and performance improvement activities in response to significant medication error.
Failed to provide training in compliance and ethics.
Failed to ensure nurse aides had required annual in-service training.
Failed to provide behavior health training consistent with requirements.
Report Facts
Residents reviewed for abuse: 17
Licensed nurses reviewed: 29
Nurses scheduled to work: 24
Residents reviewed for medication errors: 9
Residents reviewed for accidents: 14
Residents reviewed for care planning: 4
Residents reviewed for ADLs: 7
Residents reviewed for medical records accuracy: 54
CNA staff reviewed: 5
Agency staff missing QAPI training: 2
Agency staff missing Compliance and Ethics training: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E43 | Registered Nurse | Named in medication error incident involving administration of wrong resident's medications. |
| E55 | Licensed Practical Nurse | Named in medication error incident involving administration of wrong resident's medications. |
| E56 | Licensed Practical Nurse | Lacked nursing skills validation checklist and behavioral health training. |
| E57 | Agency Registered Nurse | Lacked nursing skills validation checklist, QAPI training, Compliance and Ethics training, and behavioral health training. |
| E58 | Agency Licensed Practical Nurse | Lacked nursing skills validation checklist, QAPI training, Compliance and Ethics training, and behavioral health training. |
| E11 | Named in verbal and emotional abuse incident against resident R109. | |
| E52 | Registered Nurse | Named in failure to notify family of fall and medication competency validation issues. |
| E53 | Certified Nursing Assistant | Named in failure to use hoyer lift during resident transfer. |
| E54 | Certified Nursing Assistant | Named in failure to use hoyer lift during resident transfer. |
| E48 | Staff Educator | Confirmed lack of nursing skills validation and training records for multiple staff. |
| E44 | House Supervisor | Involved in medication error incident and reporting. |
| E45 | Certified Occupational Therapy Assistant | Witnessed medication error incident and assisted resident. |
| E18 | Licensed Practical Nurse | Interviewed regarding medication refusals and pressure ulcer care. |
| E36 | Utilization Management Nurse | Involved in medication error reporting and investigation. |
| E2 | Director of Nursing | Involved in multiple interviews and findings review. |
| E1 | Nursing Home Administrator | Involved in multiple interviews and findings review. |
| E3 | Assistant Director of Nursing | Involved in multiple interviews and findings review. |
| E10 | Vice President of Operations | Involved in multiple interviews and findings review. |
Inspection Report
Annual Inspection
Deficiencies: 21
Date: Sep 10, 2024
Visit Reason
The inspection was conducted as part of a regulatory annual survey to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including resident dignity, abuse reporting, care planning, medication administration, staff competencies, food service, immunizations, and infection control. Several immediate jeopardy issues related to medication errors and staff competency were identified and abated during the survey.
Deficiencies (21)
The facility failed to ensure the urinary collection container was placed in a privacy bag for resident R422, compromising dignity.
The facility failed to timely report suspected abuse and neglect, including sexual abuse allegations involving residents R344 and R172.
The facility failed to develop and implement comprehensive person-centered care plans for six residents, including bladder and bowel continence plans and care for contractures.
The facility failed to review and revise care plans for residents R320 and R31, including incontinence care and passive range of motion interventions.
The facility failed to provide appropriate care to maintain or improve range of motion for resident R105, including failure to apply a prescribed left hand palm guard.
The facility failed to ensure adequate supervision and use of assistive devices to prevent accidents for residents R324, R170, and R270.
The facility failed to conduct bowel and bladder assessments and develop individualized care plans to promote continence for residents R90, R111, R118, R165, and R170.
The facility failed to provide safe and sanitary nephrostomy catheter care for resident R111 to prevent urinary tract infections.
The facility failed to ensure resident R90 received oxygen therapy per physician's orders.
The facility failed to ensure nursing staff had appropriate competencies and skills validated, including medication administration, resulting in an Immediate Jeopardy related to a significant medication error involving resident R322.
The facility failed to complete annual performance reviews for two nursing assistants (E25 and E26).
The facility failed to ensure a licensed pharmacist performed monthly drug regimen review and failed to act on a pharmacy recommendation for resident R107.
The facility failed to ensure residents were free from significant medication errors, including a serious medication error involving resident R322 and medication errors involving residents R95, R22, and R33.
The facility failed to observe nurse aides' job performance and provide regular training for two CNAs (E25 and E26).
The facility failed to ensure food was palatable and served at appropriate temperatures for residents R21, R90, R119, and R172.
The facility failed to provide food that accommodated resident R126's allergy to aspartame.
The facility failed to provide evidence that residents R21 and R26 were offered or declined pneumococcal and influenza vaccinations.
The facility failed to provide evidence that resident R26 was offered or declined the COVID-19 vaccine.
The facility failed to provide required annual training on abuse, neglect, exploitation, and dementia for three employees and dementia training for one employee.
The facility failed to provide required training on Quality Assurance and Performance Improvement (QAPI) and Compliance and Ethics Program for two agency nursing staff.
The facility failed to provide required Behavioral Health training for five nursing staff.
Report Facts
Residents reviewed for abuse: 17
Episodes of urinary incontinence: 64
Episodes of bowel incontinence: 2
Episodes of urinary incontinence: 11
Episodes of urinary incontinence: 29
Episodes of bowel incontinence: 19
Episodes of bladder incontinence: 118
Episodes of bowel incontinence: 60
Residents reviewed for accidents: 14
Residents reviewed for medication administration: 9
Nurses reviewed for competency: 29
Nurses scheduled to work: 24
Nurses reviewed for behavioral health training: 5
Employees sampled for abuse and dementia training: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E43 | Registered Nurse | Involved in significant medication error resulting in Immediate Jeopardy; lacked competency validation |
| E55 | Licensed Practical Nurse | Administered wrong medications to resident R95; lacked competency validation and behavioral health training |
| E56 | Licensed Practical Nurse | Lacked nursing skills validation and behavioral health training |
| E57 | Agency Registered Nurse | Lacked nursing skills validation, QAPI training, compliance and ethics training, and behavioral health training |
| E58 | Agency Licensed Practical Nurse | Lacked nursing skills validation, QAPI training, compliance and ethics training, and behavioral health training |
| E2 | Director of Nursing | Confirmed multiple deficiencies and lack of documentation |
| E3 | Assistant Director of Nursing | Confirmed multiple deficiencies and lack of documentation |
| E1 | Nursing Home Administrator | Reviewed and discussed findings with survey team |
| E48 | Staff Educator | Confirmed lack of competency and training documentation for nursing staff |
| E44 | House Supervisor | Involved in medication error incident response |
| E45 | Certified Occupational Therapy Assistant | Witnessed medication error incident |
Inspection Report
Follow-Up
Census: 119
Deficiencies: 0
Date: Mar 7, 2024
Visit Reason
An unannounced Follow-Up Survey to the Annual, Complaint, Emergency Preparedness and Extended Surveys ending September 25, 2023, was conducted by the State of Delaware Division of Health Care Quality on March 7, 2024.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities as of March 7, 2024. No deficiencies were identified at the time of the survey.
Report Facts
Survey sample size: 3
Inspection Report
Follow-Up
Census: 124
Deficiencies: 2
Date: Feb 16, 2024
Visit Reason
An unannounced second Follow-up Survey to the Annual, Complaint, Emergency Preparedness and Extended Survey ending 9/25/23 was conducted by the State of Delaware Division of Health Care Quality from February 14, 2024 through February 16, 2024.
Findings
The facility was found not to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care as of February 16, 2024. Deficiencies included failure to ensure neurological assessments were completed accurately and timely, and failure to ensure proper nursing supervision staffing levels. The facility submitted plans for correction and a date of compliance of 3/2/2024.
Deficiencies (2)
Failure to ensure that resident R1's neurological assessments were completed accurately and timely after a fall on 2/4/24, including incomplete neuro assessments and failure to monitor pain and vital signs properly.
Failure to meet minimum staffing levels for nursing supervisors, specifically incorrectly scheduling an LPN as supervisor on night shifts.
Report Facts
Facility census: 124
Sample size: 19
Date of compliance: Mar 2, 2024
Number of neuro assessments missed: 3
Number of neuro assessments with inaccurate pain capture: 5
Number of residents sent to hospital: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca White | LNHA | Provider's signature on report |
| E5 | LPN/Nursing Supervisor | Assigned Nursing Supervisor on 3 PM - 11 PM shift on 2/4/24; involved in neuro assessments and documentation |
| E6 | Agency RN | Confirmed E5 was assigned Nursing Supervisor; performed neuro assessments and interviews |
| E7 | Agency RN | Confirmed E5 was assigned Nursing Supervisor; worked on medication cart during 3 PM - 11 PM shift |
| E9 | LPN | Performed neuro assessments for resident R1; admitted to mistakes in pain section |
| E10 | CNA | Reported on BLS crew member's reaction during resident R1's incident |
| E1 | NHA | Participated in exit conference |
| E2 | DON | Participated in exit conference; involved in staffing plan |
| E3 | ADON | Participated in exit conference |
| E4 | VPO | Participated in exit conference |
Inspection Report
Follow-Up
Census: 148
Deficiencies: 14
Date: Dec 22, 2023
Visit Reason
An unannounced Follow Up, Complaint and Emergency Preparedness survey was conducted at the facility from December 11, 2023 through December 22, 2023. The survey incorporated follow-up to the Annual, Complaint, Emergency Preparedness and Extended Survey ending 9/25/23.
Findings
The facility was found not to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care as of December 22, 2023. Deficiencies were identified in areas including access to records, personnel screening, incident reporting, care planning, medication administration, infection control, and hospice services.
Deficiencies (14)
Facility failed to provide immediate access to facility records to the Survey Team.
Personnel records lacked evidence of tuberculosis screening for two of three employees reviewed.
Personnel records lacked evidence of criminal background checks, mandatory drug testing, and adult abuse registry checks for one of three employees reviewed.
Incident reports for two residents were incomplete or lacked adequate documentation.
Facility failed to report falls with injuries to the State Agency within eight hours of occurrence for two residents.
Facility failed to notify emergency contacts timely for one resident after a fall.
Comprehensive care plans for two residents did not reflect current medical conditions or treatments.
Facility failed to ensure medication administration was consistent with physician orders for multiple residents.
Facility failed to ensure oxygen concentrator filters were clean for residents receiving oxygen therapy.
Facility failed to ensure medication storage refrigerators were maintained at proper temperatures.
Facility failed to ensure food served was palatable and at appropriate temperatures.
Facility failed to complete performance reviews for two employees within required timeframes.
Facility failed to maintain accurate and complete medical records for multiple residents.
Facility failed to ensure hospice services were properly coordinated and documented.
Report Facts
Facility census: 148
Sample size: 36
Date survey completed: Dec 22, 2023
Plan of correction completion date: Jan 29, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca White | LNHA | Provider's signature on multiple pages |
| E3 | Director of Nursing (DON) | Mentioned in findings related to communication and incident reporting |
| E11 | Director of Social Services | Interviewed regarding clinical record documentation |
| E12 | Unit Manager (UM) | Interviewed regarding resident care and incident reporting |
| E13 | Licensed Practical Nurse (LPN) Unit Manager | Interviewed regarding care plans and medication administration |
| E16 | Vice President of Operations (VPO) | Interviewed during exit conference |
| E21 | DON | Interviewed during exit conference and mentioned in findings |
| E28 | Certified Nursing Assistant (CNA) | Mentioned in performance review deficiency |
| E29 | Certified Nursing Assistant (CNA) | Mentioned in performance review deficiency |
| E30 | Nurse | Interviewed regarding medication administration and clinical records |
| E35 | Consultant Pharmacist | Interviewed regarding medication reviews |
| E6 | Dietary Director | Interviewed regarding food service and tray temperatures |
| R11 | Resident | Mentioned in food service findings |
Inspection Report
Annual Inspection
Census: 154
Capacity: 177
Deficiencies: 16
Date: Sep 25, 2023
Visit Reason
An unannounced Annual, Complaint, Emergency Preparedness and Extended Survey was conducted from August 16, 2023 through September 25, 2023 to assess compliance with applicable federal and state regulations.
Findings
The survey identified multiple deficiencies including failures in tuberculosis screening for employees, criminal background checks, mandatory drug testing, adult abuse registry checks, incident reporting, staffing levels, emergency preparedness training, care planning, abuse prevention, and resident rights. The facility census was 154 with a sample of 76 residents reviewed.
Deficiencies (16)
Eight out of sixteen employees lacked evidence of two-step tuberculosis screening.
Seven out of sixteen employees lacked evidence of criminal background checks, mandatory drug testing, and adult abuse registry checks.
Facility failed to complete and retain adequate incident reports for resident R32's falls.
Facility failed to notify the State Agency of air conditioning outages lasting more than eight hours.
Facility failed to ensure pre-employment mandatory drug testing for marijuana/cannabis and phencyclidine (PCP).
Facility failed to maintain minimum staffing levels of 3.28 hours of direct care per resident per day on reviewed days.
Facility failed to have a full-time assistant director of nursing and full-time director of in-service education.
Facility failed to provide emergency preparedness training at least annually to all employees.
Facility failed to ensure availability of State survey results and complaint investigation reports in a binder accessible to residents.
Facility failed to provide adequate documentation of advance directives and resident rights.
Facility failed to ensure residents were free from verbal and physical abuse, including failure to protect resident R162 from abuse by staff.
Facility failed to implement a grievance policy and process ensuring timely resolution and documentation.
Facility failed to provide accurate assessments, care plans, and coordination of PASARR for residents.
Facility failed to provide adequate care and services to residents including skin and wound care, toileting, grooming, and personal hygiene.
Facility failed to provide adequate supervision and care to prevent falls and injuries.
Facility failed to provide adequate oral care and maintain resident hygiene for resident R407.
Report Facts
Facility census: 154
Sample size: 76
Employees lacking tuberculosis screening: 8
Employees lacking criminal background checks: 7
Employees lacking mandatory drug testing: 7
Employees lacking adult abuse registry checks: 7
Residents reviewed for incident reports: 14
Residents reviewed for PASARR: 4
Residents reviewed for abuse: 15
Staffing hours required: 3.28
Staffing hours provided: 3.05
Staffing hours provided: 2.9
Staffing hours provided: 3.24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca White | NHA | Named as Nursing Home Administrator and signer of report pages |
| E1 | Nursing Home Administrator | Interviewed and involved in findings and corrective actions |
| E2 | Regional Clinical Director | Interviewed and involved in findings and corrective actions |
| E3 | Interim DON | Interviewed and involved in findings and corrective actions |
| E24 | Maintenance Director | Interviewed regarding air conditioning issues |
| E40 | RN | Named in drug testing and tuberculosis screening deficiencies |
| E33 | Agency LPN | Named in drug testing and tuberculosis screening deficiencies |
| E38 | Dietician | Named in drug testing and tuberculosis screening deficiencies |
| E85 | PTA | Named in drug testing and tuberculosis screening deficiencies |
| E59 | LPN | Interviewed regarding wound care refusal |
| E47 | CNA | Interviewed regarding wound care refusal |
| E67 | CNA | Interviewed regarding resident care and abuse investigation |
| E75 | Former RN | Named in abuse investigation |
| E162 | Resident involved in abuse investigation | |
| E25 | Social Worker | Interviewed regarding advance directives and care planning |
| E109 | CNA | Interviewed regarding resident care |
Inspection Report
Deficiencies: 19
Date: Sep 25, 2023
Visit Reason
The inspection was conducted to investigate multiple complaints and concerns related to resident care, abuse, medication management, care planning, infection control, and facility administration at Pike Creek Nursing & Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to notify family of resident incidents, verbal and physical abuse by staff, inadequate abuse policies and reporting, inaccurate resident assessments, incomplete and untimely care plans, failure to provide necessary care and assistance with activities of daily living, inadequate pain management, medication errors, improper medication storage, incomplete medical records, failure to maintain nurse staffing records, and failure to implement infection control measures during a COVID-19 outbreak.
Deficiencies (19)
Failure to notify resident's emergency contact after a fall and hospital transfer.
Verbal and physical abuse of resident by nurse, including name-calling and inappropriate handling.
Facility abuse policy failed to include procedures to protect residents during investigations.
Failure to timely report suspected abuse and neglect to proper authorities.
Failure to investigate and document corrective action for alleged abuse.
Failure to ensure accurate resident assessments, including cognitive status, wounds, and language needs.
Failure to develop and implement baseline and comprehensive care plans addressing residents' needs.
Failure to provide necessary assistance with activities of daily living including grooming, toileting, and personal hygiene.
Failure to provide resident-centered activities that incorporate resident's interests and cultural preferences.
Failure to provide appropriate treatment and care according to orders, resident preferences, and goals, including fluid management and wound care.
Failure to provide adequate supervision and accident prevention resulting in falls and fractures.
Failure to provide appropriate bowel and bladder care, assessments, and toileting programs.
Failure to provide safe, appropriate pain management resulting in uncontrolled pain and delayed medication administration.
Failure to store medications requiring refrigeration at proper temperatures and secure controlled substances.
Failure to maintain posted daily nurse staffing data for a minimum of 18 months.
Failure to procure, store, prepare, distribute and serve food in accordance with professional standards.
Failure to ensure complete medical records for residents, including documentation of care and activities.
Failure to ensure sufficient nursing staff with appropriate competencies and skills to provide nursing services.
Failure to obtain laboratory tests as ordered and promptly notify ordering practitioner of results.
Report Facts
Medication doses missed: 5
Episodes of loose stools: 88
Episodes of loose stools: 115
Episodes of loose stools: 56
Episodes of loose stools: 25
Episodes of loose stools: 115
Episodes of loose stools: 88
Episodes of loose stools: 119
Episodes of loose stools: 67
Medication doses missed: 11
Medication doses missed: 6
Medication doses missed: 3
Medication doses missed: 1
Medication doses missed: 2
Medication doses missed: 2
Medication doses missed: 2
Medication doses missed: 2
Medication doses missed: 1
Medication doses missed: 2
Medication doses missed: 2
Medication doses missed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E11 | Director of Social Services | Confirmed lack of notification to resident's emergency contact after fall. |
| E3 | Director of Nursing | Confirmed lack of notification to resident's emergency contact and reviewed findings. |
| E12 | RN UM | Confirmed lack of notification to resident's emergency contact and medication order issues. |
| E34 | Former CNA | Witnessed verbal and physical abuse of resident R162. |
| E32 | Former CNA | Witnessed verbal and physical abuse of resident R162. |
| E75 | Former RN | Perpetrator of verbal and physical abuse of resident R162. |
| E1 | Nursing Home Administrator | Reviewed findings and confirmed multiple deficiencies including abuse policy and infection control. |
| E2 | Regional Clinical Director | Confirmed lack of pharmacist review and fall incident investigations. |
| E16 | VPO | Reviewed findings during exit conference. |
| E21 | Director of Nursing | Reviewed findings during exit conference. |
| E25 | Social Services | Confirmed lack of required interdisciplinary team members at care conferences. |
| E39 | CNA | Confirmed shaving is part of resident care but resident R121 was not shaved. |
| E47 | CNA | Confirmed shaving is part of resident care but resident R121 was not shaved. |
| E38 | RD | Provided nutrition assessment and documented diet orders. |
| E59 | LPN | Reported resident R26 refused wound care but did not document refusal. |
| E67 | CNA | Assigned to resident R411 and confirmed failure to provide incontinent care. |
| E69 | CNA | Assigned to resident R411 and unable to explain failure to provide care. |
| E8 | LPN | Unaware of resident R121's frequent loose stools and excoriated buttocks. |
| E76 | CNA | Confirmed resident R121 had loose stools and cream was not available. |
| E51 | LPN | Notified physician about resident R167's pain medication needs. |
| E53 | RN | Documented resident R167's request to be sent to hospital for uncontrolled pain. |
| E28 | MD | Ordered medications for resident R160 and was unaware of palliative care recommendation for R508. |
| E4 | RN UM | Confirmed medication storage issues and infection control deficiencies. |
| E93 | CNA | Delayed response to resident R508's call bell for pain medication. |
| E92 | RN | Informed about resident R508's pain and delayed medication administration. |
| E56 | LPN | Confirmed lack of bowel movement alerts and medication administration for R143. |
| E12 | LPN | Questioned incorrect medication order for R172. |
| E19 | LPN | Questioned incorrect medication order for R172. |
| E61 | Agency CNA | Reported resident R126 was always incontinent and changed in bed. |
| E36 | LPN | Confirmed no bowel and bladder evaluation for residents. |
| E57 | RN, MDS Coordinator | Confirmed lack of toileting/voiding diaries and care planning for incontinence. |
| E54 | CNA | Witnessed resident R173 fall while trying to reach urinal. |
| E60 | RN | Notified about resident R173 fall. |
| E59 | LPN | Assigned to resident R173 and witnessed fall incident. |
| E86 | LPN | Observed at nurse's station during resident R508's call bell ringing. |
| E25 | Regional Clinical Director | Confirmed lack of pharmacist reviews and fall investigations. |
| E56 | LPN | Confirmed lack of bowel movement alerts and medication administration for R143. |
| E29 | Food Service Director | Confirmed food service safety deficiencies. |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Sep 25, 2023
Visit Reason
The inspection was conducted as an annual survey of Pike Creek Nursing & Rehabilitation Center to assess compliance with federal regulations and quality of care standards.
Findings
The facility was found to have multiple deficiencies related to quality of care, pain management, respiratory care, fall prevention, dialysis care, nutrition/hydration, and medication administration. Several residents experienced harm due to failures in care, including inadequate supervision, missed treatments, and inconsistent documentation. The facility developed plans of correction with completion dates mostly by 11/30/2023.
Deficiencies (9)
Failure to ensure adequate care to prevent rehospitalization and proper treatment for multiple residents, including missed appointments and inadequate wound care.
Failure to provide adequate supervision and assistance devices to prevent accidents, resulting in falls and injuries.
Failure to ensure appropriate pain management for residents, including timely administration of medications.
Failure to provide adequate respiratory and tracheostomy care and suctioning for residents.
Failure to ensure continence care and toileting assistance for residents.
Failure to maintain nutrition and hydration status, including failure to provide therapeutic diets and monitor fluid intake.
Failure to ensure dialysis care and communication, including medication administration and monitoring of dialysis treatments.
Failure to ensure physician supervision and medical care for residents.
Failure to ensure sufficient nursing staff with appropriate competencies and skills.
Report Facts
Deficiencies cited: 9
Episodes of loose stools: 115
Episodes of loose stools: 88
Fluid intake: 1140
Fall score: 12
Pain scale: 10
Medication doses missed: 11
Inspection Report
Annual Inspection
Deficiencies: 14
Date: Sep 25, 2023
Visit Reason
The inspection was conducted as an annual survey of Pike Creek Nursing & Rehabilitation Center to assess compliance with federal regulations and to identify any deficiencies in resident care, staffing, medication management, infection control, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including insufficient nursing staff to meet residents' needs, failure to complete timely medication administration and pain management, inadequate nurse aide performance reviews, failure to maintain posted nurse staffing information, deficiencies in drug regimen review, food safety and menu adequacy, infection control program implementation, resident records completeness, and hospice services coordination. The facility also failed to provide required training for abuse, neglect, and exploitation prevention and quality assurance performance improvement activities.
Deficiencies (14)
Facility failed to have sufficient nursing staff to provide basic nursing care services to meet residents' needs.
Failure to provide pain medication to a resident in a timely manner and failure to acknowledge or implement recommendations.
Facility failed to complete nurse aide performance reviews at least every 12 months.
Facility failed to maintain posted daily nurse staffing data for a minimum of 18 months.
Facility failed to conduct monthly drug regimen reviews and failed to report irregularities to appropriate staff.
Facility failed to ensure residents were free from unnecessary psychotropic medication use.
Facility failed to ensure food was palatable and menus reflected the correct scheduled week.
Facility failed to maintain medication rooms at proper temperatures and failed to securely store Schedule II controlled drugs.
Facility failed to maintain complete and accurate medical records for residents.
Facility failed to maintain a written transfer agreement with a local hospital.
Facility failed to ensure hospice services were coordinated and documented properly.
Facility failed to provide required training for abuse, neglect, exploitation, and dementia management.
Facility failed to implement an effective infection prevention and control program, including failure to conduct contact tracing and testing during a COVID-19 outbreak.
Facility failed to ensure residents received COVID-19 vaccinations and education.
Report Facts
Residents reviewed for nursing staff sufficiency: 15
Residents reviewed for nurse aide performance review: 6
Residents reviewed for medication regimen review: 7
Residents reviewed for hospice services: 4
Residents reviewed for COVID-19 vaccination: 5
Date of completion for corrective actions: Most corrective actions have a completion date of 11/30/2023
Inspection Report
Deficiencies: 2
Date: Apr 13, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights and provision of medically-related social services, including review of COVID-19 mask policies and discharge planning for residents.
Findings
The facility failed to allow residents free of COVID-19 or exposure to COVID-19 to choose whether to wear masks, requiring all residents to wear masks without choice. Additionally, the facility failed to provide medically-related social services addressing a resident's social and family issues prior to discharge, including lack of follow-up on guardianship and unlivable home conditions, resulting in an AMA discharge without adequate coordination.
Deficiencies (2)
Failed to allow residents free of COVID or exposure to COVID to choose whether masks were worn.
Failed to provide medically-related social services related to a resident's social and family issues prior to discharge.
Report Facts
Residents affected: Some
Residents affected: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | NHA | Discussed findings during exit conference and interviewed regarding knowledge of resident's living condition and guardianship status. |
| E2 | DON | Interviewed regarding mask policy enforcement and resident discharge behaviors. |
| E3 | ADON | Documented resident behaviors and interviewed regarding hospital transfer and discharge. |
| E6 | SWD | Documented progress notes and interviewed regarding discharge planning. |
| E7 | Facility Hospital Liaison | Communicated intake information and interviewed regarding guardianship and discharge. |
| E10 | SW Trainee | Conducted discharge planning assessment and interviewed regarding resident's cognitive status and discharge preferences. |
| E8 | NP | Interviewed regarding resident's behaviors, hospital referral, and medication orders. |
| E9 | Admissions Director | Interviewed regarding referral information and resident's decision-making capacity. |
Inspection Report
Annual Inspection
Census: 89
Deficiencies: 8
Date: May 12, 2022
Visit Reason
The inspection was conducted as part of the annual survey of Pike Creek Nursing & Rehabilitation Center to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to ensure call bells were within reach, incomplete and inaccurate care plans, failure to monitor fluid restrictions, improper medication labeling and storage, failure to accommodate resident food preferences, failure to provide adaptive eating utensils, food safety violations, and inaccuracies in medical records documentation.
Deficiencies (8)
Failed to ensure a call bell was in reach for one resident (R55).
Failed to review and revise comprehensive person-centered care plans for two residents (R12 and R16).
Failed to monitor if fluid restriction was maintained for one resident (R388).
Failed to properly label and store medication for one resident (R16).
Failed to accommodate food preferences for one resident (R53).
Failed to provide special adaptive eating utensils for one resident (R16).
Failed to provide and store food in accordance with professional standards, including moldy food and pooling water in kitchen.
Failed to ensure accuracy of medical records for multiple residents (R26, R40, R440), including inaccurate wound care documentation and incomplete fall incident documentation.
Report Facts
Residents reviewed: 89
Residents sampled: 39
Residents reviewed for hydration: 4
Residents sampled for medication review: 6
Residents reviewed for food preferences: 3
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E12 | CNA | Responded to call bell out of reach for resident R55 |
| E10 | RN | Confirmed call bell out of reach for resident R55 |
| E2 | DON | Reviewed findings with surveyors |
| E4 | RN, UM | Provided information on COVID-19 vaccine refusals, confirmed care plan inaccuracies, and medication storage issues |
| E16 | Infection Control Practitioner | Confirmed resident R12 refused COVID-19 vaccines |
| E17 | Registered Dietitian | Completed Fluid Restriction Worksheets and discussed food preference issues |
| E19 | UM, RN | Confirmed nursing staff do not track fluid intake accurately |
| E20 | LPN | Described fluid intake monitoring practices |
| E22 | CNA | Reported communication about resident fluid intake |
| E26 | CNA | Delivered meals and confirmed food preference issues for resident R53 |
| E7 | LPN | Confirmed no built-up utensils provided to resident R16 |
| E6 | LPN | Performed wound care and medication administration with documentation inaccuracies |
| E25 | RN | Documented wound care and fall incident notes |
| E5 | LPN | Notified family of fall and documented communication attempts |
| E24 | CNA | Assigned to resident R26 and interviewed about documentation |
Report
Sep 25, 2023
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