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Deficiency Records for Pike Creek Nursing and Rehabilitation Center
A list of the most recent deficiencies for Pike Creek Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Pike Creek Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-25 | 2024-03-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-25 | 2024-01-29 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-09-25 | 2024-01-29 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-09-25 | 2024-01-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-25 | 2024-01-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-09-25 | 2024-01-29 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-09-25 | 2024-01-29 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-09-25 | 2024-01-29 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-09-25 | 2024-01-29 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-09-25 | 2024-01-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-25 | 2024-01-29 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-09-25 | 2024-01-29 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-09-25 | 2023-11-30 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-09-25 | 2023-11-30 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-09-25 | 2023-11-30 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-25 | 2023-11-30 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-25 | 2023-11-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-25 | 2023-11-30 | N |
| Respond appropriately to all alleged violations. | Health | 2023-09-25 | 2023-11-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-09-25 | 2023-11-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-25 | 2023-11-30 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-09-25 | 2023-11-30 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-09-25 | 2023-11-30 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-09-25 | 2023-11-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-25 | 2023-11-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-25 | 2023-11-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-25 | 2023-11-30 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-09-25 | 2023-11-30 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2023-09-25 | 2023-11-30 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-09-25 | 2023-11-30 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-09-25 | 2023-11-30 | N |
| Post nurse staffing information every day. | Health | 2023-09-25 | 2023-11-30 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-09-25 | 2023-11-30 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-09-25 | 2023-11-30 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-09-25 | 2023-11-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-25 | 2023-11-30 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-09-25 | 2023-11-30 | N |
| Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | Health | 2023-09-25 | 2023-11-30 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-09-25 | 2023-11-30 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-09-25 | 2023-11-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-25 | 2023-11-30 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-09-25 | 2023-11-30 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-09-25 | 2023-11-30 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-09-25 | 2023-11-30 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-09-25 | 2023-11-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-05 | 2023-10-23 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-04-13 | 2023-05-19 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-04-13 | 2023-05-19 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-19 | 2022-09-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-19 | 2022-09-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-19 | 2022-09-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-19 | 2022-09-27 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-05-12 | 2022-06-30 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-05-12 | 2022-06-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-12 | 2022-06-30 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-05-12 | 2022-06-30 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-05-12 | 2022-06-30 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-05-12 | 2022-06-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-12 | 2022-06-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-12 | 2022-06-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-12 | 2022-06-30 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-05-12 | 2022-06-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-23 | 2021-08-03 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-06-23 | 2021-08-03 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-06-23 | 2021-08-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-06-23 | 2021-08-03 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-06-23 | 2021-08-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-23 | 2021-08-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-23 | 2021-08-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-06-23 | 2021-08-03 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-06-23 | 2021-08-03 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-06-23 | 2021-08-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-23 | 2021-08-03 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-06-16 | 2021-06-28 | N |
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