Deficiencies (last 4 years)
Deficiencies (over 4 years)
58.3 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
563% worse than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
120
90
60
30
0
Occupancy
Latest occupancy rate
88% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate 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
Routine
Deficiencies: 4
Date: Aug 13, 2025
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident rights, care planning, treatment, and staffing postings at Pike Creek Nursing & Rehabilitation Center.
Findings
The facility was found deficient in promoting resident dignity, developing comprehensive care plans, providing appropriate treatment and care according to orders and preferences, and posting nurse staffing information daily. Multiple residents' rights were violated by staff entering rooms without permission and failure to provide drinkware. Care plans lacked necessary interventions and coordination with hospice services. Nurse staffing information was not posted as required.
Deficiencies (4)
F 0550: The facility failed to promote resident dignity by not providing cups or glasses with meals and staff entering resident rooms without permission.
F 0656: The facility failed to develop comprehensive person-centered care plans for two residents, lacking approaches for gastrostomy tube complications and non-pharmacological pain management.
F 0684: The facility failed to provide appropriate treatment and care by not scheduling a vascular surgery follow-up appointment and not integrating hospice care plans into the comprehensive care plan for two residents.
F 0732: The facility failed to post nurse staffing information daily, including resident census and total nursing hours worked per shift, for eight consecutive days.
Report Facts
Residents reviewed for care plans: 37
Days nurse staffing information not posted: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E3 | Director of Nursing (DON) | Interviewed regarding expectations for staff entering rooms and care plan deficiencies |
| E1 | Nursing Home Administrator (NHA) | Interviewed and participated in exit conference regarding findings |
| E4 | Assistant Director of Nursing (ADON) | Interviewed regarding care plan deficiencies |
| E10 | Licensed Social Worker (LSW) | Interviewed regarding hospice binder and care plan integration |
| 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: 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
Deficiencies: 25
Date: Sep 10, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident care, medication administration, abuse reporting, care planning, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, timely abuse reporting, comprehensive care planning, medication administration errors, inadequate staff competencies, improper food service, and incomplete staff training.
Deficiencies (25)
F0550: The facility failed to maintain resident R422's privacy by not placing the urinary collection container in a privacy bag.
F0609: The facility failed to timely report suspected abuse and failed to immediately report sexual abuse allegations involving residents R344 and R172.
F0656: The facility failed to develop and implement comprehensive person-centered care plans for six residents, including bladder and bowel continence and contracture management.
F0657: The facility failed to review and update care plans timely for residents R31 and R320, including passive range of motion and incontinence care.
F0688: The facility failed to provide appropriate care to maintain or improve range of motion for resident R105 by not applying the prescribed left hand palm guard.
F0689: The facility failed to provide adequate supervision and assistive devices to prevent accidents for residents R324, R170, and R270.
F0690: The facility failed to conduct bowel and bladder assessments and develop individualized toileting care plans for five residents (R90, R111, R118, R165, R170).
F0691: The facility failed to provide safe and sanitary nephrostomy catheter care for resident R111 to prevent urinary tract infections.
F0695: The facility failed to ensure resident R90 received oxygen therapy per physician's orders.
F0697: The facility failed to provide timely pain management for resident R173, resulting in an estimated eight-hour delay in administration of pain medication after admission.
F0726: The facility failed to ensure 29 licensed nurses had validated competencies and skills necessary to care for residents, including medication administration, resulting in significant medication errors.
F0730: The facility failed to complete annual performance reviews for two certified nursing assistants (E25 and E26).
F0756: The facility failed to act on a pharmacy medication review recommendation for resident R107 related to fall risk and medication side effects.
F0760: The facility failed to ensure residents R322, R22, R33, R95 were free from significant medication errors, including a serious medication error involving R322 receiving another resident's medications.
F0867: The facility failed to conduct a quality assurance and performance improvement process immediately and follow-through after a significant medication error involving resident R322.
F0883: The facility failed to provide evidence that pneumococcal and influenza vaccines were offered or declined for residents R21 and R26.
F0887: The facility failed to provide evidence that resident R26 consented or declined the COVID-19 vaccine.
F0943: The facility failed to provide abuse, neglect, exploitation, and dementia training at least annually for four employees (E14, E21, E27, E28).
F0944: The facility failed to ensure required Quality Assurance and Performance Improvement (QAPI) training was completed for agency staff E57 and E58.
F0946: The facility failed to ensure required Compliance and Ethics Program training was completed for agency staff E57 and E58.
F0949: The facility failed to ensure required Behavioral Health training was completed for five nursing staff (E43, E55, E56, E57, E58).
F0800: The facility failed to provide routine dental services for resident R109 for complaints of mouth pain.
F0804: The facility failed to provide food to residents that was palatable and at appetizing temperatures for residents R21, R90, R119, and R172.
F0806: The facility failed to provide food that accommodated resident R126's allergy to aspartame.
F0812: The facility failed to ensure food items in nourishment refrigerators were labeled and dated on three units.
Report Facts
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
Fall risk score: 12
Fall risk score: 16
Weight: 210
Number of licensed nurses reviewed: 29
Number of nursing staff missing abuse and dementia training: 3
Number of nursing staff missing QAPI training: 2
Number of nursing staff missing Compliance and Ethics training: 2
Number of nursing staff missing Behavioral Health training: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E43 | Registered Nurse | Involved in significant medication error administering wrong resident's medications |
| E55 | Licensed Practical Nurse | Involved in medication administration error and lacked competency validation |
| E56 | Licensed Practical Nurse | Lacked nursing skills validation and behavioral health training |
| E57 | Agency Registered Nurse | Lacked nursing skills validation, QAPI, Compliance and Ethics, and Behavioral Health training |
| E58 | Agency Licensed Practical Nurse | Lacked nursing skills validation, QAPI, Compliance and Ethics, and Behavioral Health training |
| E14 | Certified Nursing Assistant | Lacked abuse and dementia training |
| E21 | Certified Nursing Assistant | Lacked dementia training |
| E27 | Certified Nursing Assistant | Lacked abuse and dementia training |
| E28 | Certified Nursing Assistant | Lacked abuse and dementia training |
| E2 | Director of Nursing | Confirmed multiple findings and lack of documentation |
| E3 | Assistant Director of Nursing | Confirmed multiple findings and lack of documentation |
| E1 | Nursing Home Administrator | Reviewed findings and abatement plans |
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
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
Complaint Investigation
Deficiencies: 27
Date: Sep 25, 2023
Visit Reason
The inspection was conducted due to complaint investigations and routine oversight of the nursing home facility.
Complaint Details
The inspection was complaint-related, investigating multiple allegations including failure to notify emergency contacts, abuse, inadequate care, medication errors, and infection control deficiencies.
Findings
The facility was found to have multiple deficiencies including failure to notify emergency contacts, verbal and physical abuse incidents, inaccurate resident assessments, incomplete care plans, inadequate assistance with activities of daily living, failure to prevent accidents, medication errors, incomplete medical records, and failure to maintain infection control during a COVID-19 outbreak.
Deficiencies (27)
F580 - The facility failed to notify a resident's emergency contact when the resident fell and was transferred to the hospital.
F600 - The facility failed to protect a resident from verbal and physical abuse by a nurse who called the resident a dumbass and pulled a gown over his head.
F607 - The facility's abuse policy lacked written procedures to protect residents from harm during investigations.
F609 - The facility failed to timely report an allegation of abuse to the proper authorities.
F610 - The facility failed to investigate and document corrective action for an alleged abuse violation.
F641 - The facility failed to ensure accurate resident assessments, including proper documentation of fractures, wounds, and use of certified translators.
F655 - The facility failed to develop and implement baseline care plans addressing residents' immediate needs such as epilepsy and skin integrity.
F656 - The facility failed to develop and implement comprehensive care plans with timely interventions for skin/wound care and urinary catheter management.
F657 - The facility failed to revise care plans timely and ensure required interdisciplinary team members attended care conferences.
F677 - The facility failed to provide adequate assistance with activities of daily living including toileting, grooming, and personal hygiene.
F679 - The facility failed to provide resident-centered activities that incorporated residents' cultural preferences and interests.
F684 - The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals, including failure to monitor fluid restrictions, bowel movements, wound care, and medication administration.
F689 - The facility failed to ensure a nursing home area was free from accident hazards and failed to provide adequate supervision to prevent accidents, resulting in falls and injuries.
F690 - The facility failed to provide appropriate care for residents who were continent or incontinent of bowel/bladder, including lack of assessments and toileting programs.
F697 - The facility failed to provide safe, appropriate pain management, including failure to timely provide pain medication and implement palliative care recommendations.
F710 - The facility failed to obtain a doctor's order to admit a resident and ensure accurate medication orders, resulting in incorrect medication administration instructions and critical health events.
F726 - The facility failed to ensure nurses and nurse aides had appropriate competencies and skills to provide nursing services, including failure to manage constipation and anemia.
F732 - The facility failed to post daily nurse staffing data for a minimum of 18 months as required.
F756 - The facility failed to ensure a licensed pharmacist performed monthly drug regimen reviews and failed to respond to pharmacist recommendations in a timely manner.
F760 - The facility failed to ensure residents were free from significant medication errors, including missed doses of seizure and anticoagulant medications.
F761 - The facility failed to ensure drugs and biologicals were stored properly, including failure to maintain refrigerator temperatures and secure controlled substances.
F773 - The facility failed to provide or obtain laboratory tests when ordered and failed to promptly inform the ordering practitioner of results.
F803 - The facility failed to ensure menus met nutritional needs, were prepared in advance, followed, updated, reviewed by a dietician, and met resident needs.
F804 - The facility failed to ensure food was palatable, attractive, and served at a safe and appetizing temperature.
F812 - The facility failed to procure food from approved sources and failed to store, prepare, distribute, and serve food in accordance with professional standards.
F835 - The facility failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently, including failure to maintain infection control during a COVID-19 outbreak and failure to maintain key staff positions.
F842 - The facility failed to safeguard resident-identifiable information and maintain complete medical records.
Report Facts
Deficiencies cited: 32
Residents reviewed: 76
Episodes of loose stools: 88
Episodes of loose stools: 115
Missed medication doses: 6
Missed medication doses: 5
Fall score: 12
Fall score: 13
Medication doses not administered: 11
Meal intakes undocumented: 18
Bedtime snacks undocumented: 9
Bowel/bladder elimination undocumented: 22
Shower opportunities undocumented: 2
Personal hygiene undocumented: 13
Eating undocumented: 13
Dressing undocumented: 13
Bed mobility undocumented: 20
Loose stools episodes: 56
Loose stools episodes: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E11 | Director of Social Services | Confirmed lack of notification to resident's emergency contact |
| E3 | Director of Nursing | Confirmed lack of notification and other findings |
| E75 | Former RN | Named in verbal and physical abuse of resident R162 |
| E54 | CNA | Witnessed fall of resident R173 and lack of supervision |
| E1 | Nursing Home Administrator | Interviewed regarding multiple findings and staffing |
| E2 | Regional Clinical Director | Interviewed regarding multiple findings and staffing |
| E4 | RN Unit Manager | Interviewed regarding infection control and staffing |
| E17 | Nurse Practitioner | Interviewed regarding medication errors and lab orders |
| E28 | Physician | Named in medication orders and pain management |
| E51 | LPN | Named in pain medication administration and communication |
| E93 | CNA | Observed delayed response to call bell for pain |
| E57 | RN, MDS Coordinator | Interviewed regarding continence assessments |
| E29 | Food Service Director | Confirmed food service deficiencies |
| E39 | CNA | Interviewed regarding resident care and supplies |
| E40 | RN | Interviewed regarding resident care and supplies |
| E61 | LPN | Documented medication administration issues |
| E66 | LPN | Documented medication administration issues |
| E8 | LPN | Interviewed regarding pain management |
| E18 | Nurse Practitioner | Interviewed regarding medication order error |
| E56 | LPN | Interviewed regarding bowel management |
| E36 | LPN | Interviewed regarding bowel and bladder evaluation |
| E61 | LPN | Documented medication administration and pharmacy communication |
| E12 | LPN | Interviewed regarding medication order clarification |
| E19 | LPN | Interviewed regarding medication order clarification |
Inspection Report
Deficiencies: 32
Date: Sep 25, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident care, medication management, infection control, staffing, and quality assurance.
Findings
The facility had multiple deficiencies including failure to provide adequate resident care, medication management errors, insufficient staffing, incomplete medical records, failure to implement infection control measures during a COVID-19 outbreak, and lack of proper training and quality assurance activities.
Deficiencies (32)
F 0577: The facility failed to ensure State survey results were available for residents to read as required.
F 0578: The facility failed to ensure residents were offered the choice to formulate an advance directive and that advanced directives were properly documented.
F 0585: The facility failed to implement a grievance policy and postings that included a process for residents and families to file anonymous grievances and to identify the grievance official.
F 0600: The facility failed to ensure one resident was free from verbal and physical abuse by a nurse who called the resident a dumbass and pulled a gown over his head.
F 0607: The facility policy for abuse failed to include written procedures to protect residents from further abuse during investigations.
F 0609: The facility failed to timely report an allegation of abuse to the State Agency and failed to report the allegation of abuse within required time frames.
F 0610: The facility failed to maintain documentation that appropriate corrective action was taken after an alleged abuse violation.
F 0623: The facility failed to provide written notice to a resident's representative regarding an unplanned hospital transfer.
F 0641: The facility failed to ensure accurate assessments for residents, including use of appropriate translators and accurate documentation of diagnoses and treatments.
F 0644: The facility failed to ensure a referral for PASARR screening was completed following a significant change in condition.
F 0645: The facility failed to ensure Delaware State PASARR screening was obtained prior to admission for residents.
F 0655: The facility failed to develop and implement baseline care plans for residents that included instructions needed to provide effective and person-centered care.
F 0656: The facility failed to develop and implement comprehensive resident-centered care plans for identified care areas in a timely manner.
F 0677: The facility failed to provide necessary services to maintain good nutrition, grooming, and personal hygiene for residents unable to perform activities of daily living.
F 0684: The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals, including failure to monitor fluid restrictions, bowel movements, wound care, medication administration, and nutrition.
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and failed to provide adequate supervision to prevent accidents, resulting in falls and injuries.
F 0690: The facility failed to provide appropriate care for residents who were continent or incontinent of bowel/bladder, including appropriate catheter care and prevention of urinary tract infections.
F 0692: The facility failed to provide necessary services to maintain adequate nutrition for residents, including failure to provide meals during dialysis and before appointments.
F 0695: The facility failed to provide safe and appropriate respiratory care consistent with physician orders and care plans.
F 0697: The facility failed to provide safe, appropriate pain management resulting in uncontrolled pain and delayed medication administration.
F 07 61: The facility failed to have sufficient nursing staff with appropriate competencies and skills to provide nursing services to assure resident safety and well-being.
F 0732: The facility failed to post daily nurse staffing data for a minimum of 18 months as required.
F 0783: The facility failed to ensure that residents were served meals that followed the posted menu and failed to serve meals selected by residents.
F 0812: The facility failed to provide and store food in accordance with professional standards for food service safety, including unsanitary conditions in the kitchen and unsecured controlled substances.
F 0835: The facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently during a COVID-19 outbreak, including failure to maintain key staff and infection control responsibilities.
F 0842: The facility failed to safeguard resident-identifiable information and maintain complete medical records.
F 0843: The facility failed to provide evidence of a written transfer agreement with one or more hospitals certified by Medicare or Medicaid.
F 0867: The facility failed to set up an ongoing quality assessment and assurance group that measured success of actions, tracked performance, and regularly reviewed data.
F 0880: The facility failed to provide and implement an infection prevention and control program during a COVID-19 outbreak, including failure to conduct contact tracing, serial testing, and staff education.
F 0887: The facility failed to educate residents and staff on COVID-19 vaccination, offer the vaccine to eligible residents, and properly document vaccination status.
F 0944: The facility failed to provide mandatory annual training on abuse, neglect, exploitation, and dementia care for staff.
F 0943: The facility failed to provide mandatory annual training on Quality Assurance and Performance Improvement (QAPI) for staff.
Report Facts
Deficiencies cited: 37
Immediate jeopardy: 1
Residents affected by abuse: 1
Residents affected by inadequate care: 8
Residents affected by medication errors: 7
Residents affected by infection control failures: 4
Residents affected by nutrition failures: 2
Residents affected by pain management failures: 2
Residents affected by falls: 3
Residents affected by hospice care failures: 4
Residents affected by COVID-19 vaccination failures: 1
Staff with overdue performance reviews: 5
Missing nurse staffing postings: 3
Missing QAPI meetings: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator | Named in multiple findings and interviews |
| E2 | Regional Clinical Director | Named in multiple findings and interviews |
| E3 | Director of Nursing | Named in multiple findings and interviews |
| E25 | Social Worker | Named in advance directive and PASARR findings |
| E40 | Registered Nurse | Named in respiratory care and training findings |
| E59 | Licensed Practical Nurse | Named in wound care and pressure ulcer findings |
| E87 | Licensed Practical Nurse | Named in training findings |
| E88 | Certified Nursing Assistant | Named in training findings |
| E89 | Social Services | Named in training findings |
| E54 | Certified Nursing Assistant | Named in fall incident involving resident R173 |
| E51 | Licensed Practical Nurse | Named in pain management failure for R167 |
| E93 | Certified Nursing Assistant | Named in pain management failure for R508 |
| E4 | Registered Nurse Unit Manager | Named in infection control and pain management findings |
| E17 | Nurse Practitioner | Named in multiple medication and pain management findings |
| E2 | Regional Clinical Director | Named in medication regimen review and hospice findings |
| E1 | Nursing Home Administrator | Named in multiple interviews and findings |
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
Complaint Investigation
Deficiencies: 2
Date: Apr 13, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to allow residents free of COVID or exposure to COVID to choose whether to wear masks, and failure to provide medically-related social services to a resident prior to discharge.
Complaint Details
The complaint investigation was substantiated. The facility was found to have failed in allowing resident choice regarding mask-wearing and in providing necessary social services to a resident prior to discharge, including failure to follow up on guardianship and housing issues.
Findings
The facility failed to respect residents' choice regarding mask-wearing despite CDC guidelines and facility policy. Additionally, the facility failed to provide adequate medically-related social services to a resident with complex social and family issues prior to discharge, including lack of follow-up on guardianship and unlivable home conditions.
Deficiencies (2)
F 0561: The facility failed to allow residents free of COVID or exposure to COVID to choose whether masks were worn, requiring all residents to wear masks without offering choice.
F 0745: The facility failed to provide medically-related social services to a resident prior to discharge, neglecting to address social and family issues including guardianship and unlivable home conditions.
Report Facts
Residents observed wearing masks: 6
Residents sampled for discharge review: 3
Residents affected by mask-wearing deficiency: Described as 'Some' residents
Residents affected by social services deficiency: Described as 'Few' residents
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Clerk | Interviewed about mask-wearing policy | |
| CNA | Confirmed mask-wearing expectations | |
| NHA | Discussed findings during exit conference and follow-up interviews | |
| DON | Discussed findings during exit conference and interviewed about resident situation | |
| E7 | Facility Hospital Liaison | Provided email correspondence and intake information regarding resident discharge |
| E10 | Social Worker Trainee | Conducted discharge planning assessment |
| E3 | ADON | Documented nurse notes and interviewed about resident behavior and hospital transport |
| E6 | Social Worker Director | Documented progress notes and interviewed about discharge planning |
| E8 | Nurse Practitioner | Interviewed about resident condition and hospital referral |
| E9 | Admissions Director | Interviewed about hospital liaison information and resident capacity |
| E1 | NHA | Interviewed about resident guardianship and living condition awareness |
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 |
Inspection Report
Routine
Census: 89
Deficiencies: 8
Date: May 12, 2022
Visit Reason
Routine inspection of Pike Creek Nursing & Rehabilitation Center to assess compliance with regulatory standards including resident care, medication management, food service, and medical record accuracy.
Findings
The facility was found to have multiple deficiencies including failure to ensure call bell accessibility, incomplete and inaccurate care plans, improper medication labeling and storage, failure to accommodate resident food preferences, inadequate provision of adaptive eating utensils, unsafe food storage practices, and inaccuracies in clinical records.
Deficiencies (8)
F 0558: The facility failed to ensure a call bell was within reach for one resident (R55) out of 89 reviewed during observations on 5/3/22.
F 0657: The facility failed to review and revise comprehensive person-centered care plans for two residents (R12 and R16) out of 39 sampled.
F 0684: The facility failed to monitor fluid restriction compliance for one resident (R388) out of four reviewed for hydration.
F 0761: The facility failed to properly label and store medication for one resident (R16) out of six sampled for unnecessary medication review.
F 0806: The facility failed to accommodate food preferences for one resident (R53) out of three reviewed, including failure to provide preferred hot tea and correct soups.
F 0810: The facility failed to provide special adaptive eating utensils for one resident (R16) during a meal observation.
F 0812: The facility failed to provide and store food in accordance with professional standards, including moldy food and water pooling on the floor observed in the kitchen.
F 0842: The facility failed to ensure accuracy of medical records for three residents (R26, R40, and R440), including inaccurate wound care documentation, failure to document guardian contact, and inaccurate shower/bath records.
Report Facts
Residents reviewed: 89
Residents sampled: 39
Residents reviewed: 4
Residents sampled: 6
Residents reviewed: 3
Residents sampled: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E4 | RN, UM | Involved in care plan review, medication labeling, wound care observation, and interviews |
| E2 | DON | Director of Nursing, participated in exit conferences and reviewed findings |
| E1 | NHA | Nursing Home Administrator, participated in exit conferences and reviewed findings |
| E16 | Infection Control Practitioner | Interviewed regarding resident vaccination status |
| E17 | Registered Dietitian | Interviewed regarding fluid restriction and food preferences |
| E19 | UM, RN | Interviewed regarding fluid restriction documentation and care plan issues |
| E20 | LPN | Interviewed regarding fluid intake documentation |
| E22 | CNA | Interviewed regarding fluid intake documentation |
| E26 | CNA | Interviewed regarding food preferences and meal delivery |
| E7 | LPN | Interviewed regarding provision of adaptive utensils |
| E6 | LPN | Involved in wound care documentation and medication administration |
| E25 | RN | Documented progress notes related to resident fall |
| E5 | LPN | Interviewed regarding fall notification and documentation |
| E24 | CNA | Interviewed regarding shower/bath documentation |
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