Deficiencies per Year
24
18
12
6
0
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 156
Deficiencies: 14
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.
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.
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.
Severity Breakdown
Level 3: 2
Level 4: 11
Deficiencies (14)
| Description | Severity |
|---|---|
| Resident Rights/Exercise of Rights - Facility failed to promote resident dignity and respect during dining and entering resident rooms without permission. | Level 3 |
| Grievances - Facility failed to ensure prompt resolution and proper documentation of grievances. | Level 4 |
| Reporting of Alleged Violations - Facility failed to report an incident involving a resident to the State Agency within required timeframes. | Level 4 |
| Discharge Process - Facility failed to provide timely and adequate notice of transfer or discharge to residents and representatives. | Level 4 |
| Develop/Implement Comprehensive Care Plan - Facility failed to develop and implement comprehensive person-centered care plans for residents. | Level 4 |
| Care Plan Timing and Revision - Facility failed to update care plans timely for residents with newly identified needs. | Level 4 |
| Quality of Care - Facility failed to provide care in accordance with professional standards for residents receiving hospice services. | Level 4 |
| Pain Management - Facility failed to ensure non-pharmacological interventions were attempted prior to using pain medication for residents. | Level 4 |
| Posted Nurse Staffing Information - Facility failed to post nurse staffing data daily as required. | Level 3 |
| Pharmacy Services - Facility failed to ensure accurate medication administration records and proper disposal of controlled substances. | Level 4 |
| Radiology/Diagnostic Services - Facility failed to promptly notify ordering physicians of radiology results and follow up on abnormal findings. | Level 4 |
| Drug Regimen is Free from Unnecessary Drugs - Facility failed to ensure residents' drug regimens were free from unnecessary drugs. | Level 4 |
| Food Safety Requirements - Facility failed to maintain proper food storage and handling practices, including pest control. | Level 4 |
| Maintains Effective Pest Control Program - Facility failed to ensure kitchen dry food storage room was free of pests. | Level 4 |
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
Complaint Investigation
Census: 116
Deficiencies: 0
Feb 28, 2025
Visit Reason
An unannounced complaint survey was conducted at the facility to investigate concerns raised.
Findings
No deficient practice was identified during the complaint investigation survey.
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.
Report Facts
Survey sample residents: 17
Inspection Report
Annual Inspection
Census: 169
Deficiencies: 22
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)
| Description |
|---|
| 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
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.
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.
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.
Deficiencies (10)
| Description |
|---|
| 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
Follow-Up
Census: 119
Deficiencies: 0
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
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)
| Description |
|---|
| 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
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)
| Description |
|---|
| 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
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)
| Description |
|---|
| 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
Annual Inspection
Deficiencies: 9
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.
Severity Breakdown
F689-SS=G: 1
F697-SS=G: 1
F695-SS=D: 1
F690-SS=D: 1
F692-SS=D: 1
F698-SS=D: 1
F710-SS=D: 1
F725-SS=E: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| 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. | F689-SS=G |
| Failure to ensure appropriate pain management for residents, including timely administration of medications. | F697-SS=G |
| Failure to provide adequate respiratory and tracheostomy care and suctioning for residents. | F695-SS=D |
| Failure to ensure continence care and toileting assistance for residents. | F690-SS=D |
| Failure to maintain nutrition and hydration status, including failure to provide therapeutic diets and monitor fluid intake. | F692-SS=D |
| Failure to ensure dialysis care and communication, including medication administration and monitoring of dialysis treatments. | F698-SS=D |
| Failure to ensure physician supervision and medical care for residents. | F710-SS=D |
| Failure to ensure sufficient nursing staff with appropriate competencies and skills. | F725-SS=E |
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
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)
| Description |
|---|
| 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
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