Deficiency Records for Pike Creek Nursing and Rehabilitation Center
Updated as of March 01, 2024
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? |
|---|---|---|---|---|
| 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 |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 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 safe and appropriate respiratory care for a resident when needed. | 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 |
| 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 | Y |
| 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 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-06-23 | 2021-08-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-23 | 2021-08-03 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-06-23 | 2021-08-03 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-06-23 | 2021-08-03 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-06-23 | 2021-08-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-23 | 2021-07-08 | Y |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-06-16 | 2021-06-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-03-06 | 2019-04-24 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-03-06 | 2019-04-24 | 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 | 2019-03-06 | 2019-04-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-03-06 | 2019-04-24 | 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 | 2019-03-06 | 2019-04-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-03-06 | 2019-04-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-03-06 | 2019-04-24 | N |
| Provide activities to meet all resident's needs. | Health | 2019-03-06 | 2019-04-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-06 | 2019-04-24 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-03-06 | 2019-04-24 | 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 | 2019-03-06 | 2019-04-24 | 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 | 2019-03-06 | 2019-04-24 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-03-06 | 2019-04-24 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2019-03-06 | 2019-04-24 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-03-06 | 2019-04-24 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-03-08 | 2019-04-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-03-08 | 2019-04-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-08 | 2019-04-02 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-03-08 | 2019-04-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-03-08 | 2019-04-02 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2019-03-08 | 2019-04-02 | N |
