Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cadia Rehabilitation Pike Creek during CMS and state inspections, most recent first.
Sanitary Food Service Practices Not Followed: A dietary staff member with a goatee was observed prepping food without a beard guard, and multiple cleaned pans were found stacked while still wet before being fully air-dried. The FSD confirmed both observations, and facility policy required facial hair restraints and air-drying of pots and pans before storage.
Missed wound treatments and failure to report skin change: The facility did not document completion of ordered pressure ulcer care for two residents with significant wounds, including a resident with multiple unstageable ulcers and a resident with a stage 4 sacral ulcer. In addition, a CNA observed a new red area on another resident’s buttock during incontinence care but did not report it to the charge nurse, and a later note documented an open area. Staff interviews confirmed that if the wound treatments were not signed off, they were not done.
Controlled meds were not properly safeguarded and an ordered med was not available for a resident. A stock oxycodone IR dose was signed for but never placed into the Omnicell and later could not be found, a resident’s lorazepam count dropped by one tablet without documentation of administration, and another resident did not receive naloxegol for several days while staff noted it was still on order and did not document provider notification.
A resident with a history of subdural hemorrhage and recent craniotomy experienced a fall and subsequently showed significant neurological decline, including lethargy, slurred speech, and inability to eat or take medications. Despite these symptoms, staff did not escalate care or arrange timely hospital transfer, resulting in delayed treatment for an acute subdural hematoma that required emergency surgery.
Two residents who required two-person assistance for bed mobility and transfers were left unsupervised by only one staff member during care, contrary to their care plans. As a result, both residents fell from their beds; one sustained a head laceration requiring emergency treatment, while the other suffered minor injuries. In both cases, staff admitted to not following the required level of assistance.
A resident's right to receive visitors at any time was not honored when her family member was restricted from visiting during evening and nighttime hours, despite the resident's wishes and no complaints from her roommate. Staff cited the presence of a roommate and posted recommended visiting hours, but there was no documentation of disruptive behavior or a formal visitation policy in place.
A resident with total incontinence and complex medical needs experienced urine odors in their room after staff disposed of soiled briefs in the room's trash can rather than the soiled utility room. Multiple staff, including CNAs and LPNs, were either unaware of or not trained on the correct disposal procedure, and family and housekeeping staff also noticed the resulting odors. The facility lacked a specific policy addressing the maintenance of a homelike environment related to this issue.
A resident who was totally dependent on staff and required two-person assistance for bed mobility sustained a fractured and dislocated shoulder. Although the injury was reported to the State Survey Agency, the facility did not conduct a thorough internal investigation, as no staff interviews or witness statements were collected, contrary to facility policy.
A resident admitted with a stage 2 sacral pressure ulcer did not receive timely wound treatment orders or documented care. Nursing staff provided undocumented treatments without provider notification, and communication lapses led to delays in wound management. The wound worsened and required debridement before appropriate orders and care were established.
Surveyors found that multiple residents with tracheostomies and complex respiratory needs did not consistently receive required tracheostomy and respiratory mouth care as ordered and documented in their care plans. Review of treatment records showed several missed or undocumented care opportunities, and staff interviews confirmed that the respiratory therapy department was responsible for these interventions.
Two residents did not receive required post-fall assessments and monitoring according to physician orders and facility policy. Nursing staff failed to obtain and document current vital signs each shift for a resident placed on alert charting after a fall, instead recording outdated information. Another resident with a seizure disorder was not properly monitored or assessed after a fall with seizure activity, with missing documentation of vital signs and seizure monitoring on subsequent shifts.
Two residents with seizure disorders did not have required lab tests for their antiseizure medications obtained or documented as ordered by providers. In one case, lab results were missing entirely, and in another, only partial results were uploaded and not reviewed by the NP for several months. These deficiencies were confirmed by facility leadership.
The facility failed to provide a safe, clean, comfortable, and homelike environment for five residents, with issues including broken and stained privacy curtains, trash and clutter in rooms, and poor communication between housekeeping and maintenance.
The facility failed to accurately code the MDS assessment for a resident, incorrectly marking a planned discharge home as a discharge to hospital. The MDS Coordinator confirmed the error and noted the absence of a specific policy for MDS coding.
The facility failed to provide advance notice of care plan meetings to a resident and did not ensure another resident was invited to participate in his quarterly care plan meeting. Both residents were cognitively intact, and the facility's policy required advance notice to promote participation, which was not followed.
The facility failed to reweigh a resident within 48 hours after a significant weight loss of 26.3 pounds, despite the resident's dependence on tube feeding and multiple diagnoses. The dietician was not informed of the weight loss in a timely manner, and there was no documentation of family notification.
A resident with chronic pain and other medical conditions experienced multiple missed doses of narcotic pain medication due to the facility's failure to ensure timely delivery and lack of alternative pain management options. The facility's policy did not address the ordering process for controlled substances or procedures for pharmacy delivery issues, leading to unresolved pain and increased anxiety for the resident.
The facility failed to provide trauma-informed, culturally competent care for two residents, leading to potential re-traumatization. Both residents had care plans that did not identify specific triggers or address the effects of trauma on their well-being, despite having diagnoses of PTSD.
The facility failed to ensure timely delivery of pain medications for a resident with chronic pain, resulting in unresolved pain. The facility lacked a policy on ordering controlled substances and did not effectively collaborate with the pharmacy, leading to multiple missed doses of Oxycodone. Interviews revealed inconsistencies in the process of ordering and delivering these medications.
Sanitary Food Service Practices Not Followed
Penalty
Summary
The facility failed to ensure kitchen staff thoroughly cleaned and air-dried pots and pans before storage, and failed to ensure staff with facial hair wore a beard guard. During an observation and interview on 05/11/26 at 9:30 AM, a dietary staff member was observed prepping food for lunch with a goatee approximately 0.25 to 0.50 inches in length and was not wearing a beard guard. The staff member stated he did not think the facial hair was long enough to need to be covered. The Regional Food Service Director was present and confirmed the staff member was not wearing a beard guard and provided one. During a separate observation and interview on 05/11/26 at 9:35 AM, the Food Service Director confirmed that two pans measuring 6 inches by 12 inches by 4 inches, seven pans measuring 6 inches by 6 inches by 6 inches, and five pans measuring 12 inches by 18 inches by 3 inches were cleaned and stacked for use while still wet. The pans had been stacked before they were fully dry and were not given adequate time to air-dry before being stored. The facility policy titled, Personnel Adherence to Sanitary Procedures, required hair nets, caps, beard nets, approved hats, or other effective hair restraints to cover all hair while on duty, and the policy titled, Washing Pots and Pans, required pots and pans to be placed on a drying rack to air dry before being moved to the pan rack.
Missed wound treatments and failure to report new skin change
Penalty
Summary
The facility failed to ensure ordered pressure ulcer treatments were completed for three residents and failed to ensure a newly identified skin change was reported for one resident. The deficiency was identified through record review and staff interviews and involved missed wound treatment documentation for residents with significant medical complexity and dependence on staff for care. For one resident, the record showed admission with spinal muscular atrophy, pneumonia, acute and chronic respiratory failure with hypoxia, severe sepsis with septic shock, severe protein-calorie malnutrition, hypotension, polyneuropathy, and generalized muscle weakness. The resident was cognitively intact, totally dependent for bed mobility, transfers, bathing, toileting, and toileting hygiene, and always incontinent of bowel and bladder. The resident had three unstageable pressure ulcers present on admission. Physician orders directed daily wound care to the bilateral buttocks and sacrum, but the wound treatment administration record and progress notes did not document completion of ordered treatments to the right and left buttocks on two dates and to the sacrum on one date, and there was no clinical rationale documented for the missed treatments. For another resident, the record showed a vegetative state due to anoxic brain injury, ventilator dependence, dependence on staff for all ADLs, and bowel and bladder incontinence. The resident had an unhealed stage 4 sacral pressure ulcer present on admission. Orders changed over time for sacral wound care, including cleansing and application of hydrofera blue or alginate with dry dressing on scheduled days. Review of the wound treatment administration records and progress notes showed missed documentation of ordered sacral wound treatments on four separate dates, with no documentation explaining why the treatments were not completed. For the third resident, the record showed severe cognitive impairment, high risk for pressure ulcers, total dependence for ADLs, and use of a Hoyer lift for transfers. The care plan included interventions to prevent skin breakdown and promote skin integrity. A family member and a CNA observed a new red/discolored area on the right upper buttock during incontinence care, and the CNA stated he did not report the skin change to the charge nurse as required by facility protocol. A later progress note documented an open area on the upper right buttock. The unit manager confirmed the resident’s newly identified skin change and noted the Kardex did not reflect skin concerns.
Controlled medications were not secured and an ordered medication was unavailable
Penalty
Summary
The facility failed to safeguard controlled medications used in facility stock and failed to safeguard controlled medications and ensure the availability of physician-ordered medications for two residents. One event involved a stock replacement dose of oxycodone IR 5 mg delivered to the facility for the Omnicell. The pharmacy delivery manifest showed the pill was received and signed for by an LPN, but later the DON learned the medication had never been placed into the Omnicell. The DON stated the Omnicell was not working at the time, the pill was given to an RN unit manager to hold until the cabinet was working, and the medication could not later be located after searches of medication rooms and carts. The DON stated police were called, a report was filed, and the RN unit manager was terminated. Facility policy required Schedule II-V medications to be stored in a double-locked compartment, with the nurse on duty maintaining possession of the key. A second event involved a resident with severe cognitive impairment, hemiplegia, hemiparesis, aphasia, and seizures who had an order for lorazepam 0.5 mg every eight hours as needed for anxiety. The controlled drug count showed nine tablets at the start of the shift and eight tablets at the end of the shift, but the resident was not documented as receiving the medication that day. The LPN stated she did not administer lorazepam to the resident and did not know what happened to the missing tablet, though she thought it may have fallen out while cleaning the medication cart. She reported the missing pill to the DON, and the DON stated she and the ADON searched the cart, medication room, and unit without finding it. The DON stated police were called, a report was filed, and the LPN was terminated. A third event involved a resident with constipation, IBS, and a history of fecal impaction who had an order for naloxegol oxalate 25 mg each morning. The MAR showed the medication was not administered for several consecutive days, and progress notes stated it was pending delivery from the pharmacy or still on order. The record did not show that staff contacted the provider to notify them that the medication remained unavailable. The resident stated he had not received the medication for the last four days. RN2 later verified the pharmacy had not delivered the medication and stated nurses were responsible for ordering medications and, if unavailable, were to contact the pharmacy and physician and obtain an order to hold the medication or replace it with one that was available. The DON stated staff were responsible for ordering medications and that this was missed.
Failure to Provide Timely Treatment for Change in Condition After Fall
Penalty
Summary
A deficiency occurred when a resident with a history of traumatic subdural hemorrhage and recent craniotomy was not provided timely treatment following a fall and subsequent change in condition. After being admitted to the facility with severe cognitive impairment, the resident experienced a fall, hitting his head and sustaining facial injuries. Although neurological checks were initiated and the nurse practitioner was notified, the resident began to exhibit significant changes in mental status, including increased lethargy, inability to wake for medications or meals, slurred speech, and decreased responsiveness over the following days. Despite these clear signs of neurological decline, the facility staff did not escalate care or send the resident to the hospital in a timely manner. Documentation shows that the resident's condition worsened, with persistent lethargy and confusion, and therapy notes indicated a marked decline in functional status. The on-call nurse practitioner was notified but only advised holding medications and monitoring, without further intervention. The resident's family expressed concern and ultimately insisted on hospital transfer, at which point the resident was found to have a large subdural hematoma with midline shift, requiring emergency craniotomy and intubation. Interviews with facility staff revealed that the change in the resident's condition was recognized but not acted upon appropriately, and there was a lack of escalation to higher-level providers or the medical director. The facility failed to identify the seriousness of the resident's symptoms and did not implement any corrective measures following the incident, resulting in a delay in treatment for a life-threatening condition.
Failure to Provide Required Two-Person Assistance During Bed Mobility and Transfers
Penalty
Summary
The facility failed to ensure that two residents who required assistance from two staff members for bed mobility and transfers were provided with the necessary supervision and support, resulting in accidents. In both cases, only one staff member provided care despite the residents' care plans and transfer status sheets clearly indicating the need for two-person assistance. This failure to follow the prescribed care plans led to both residents falling from their beds during care. One resident, who had anoxic brain damage and was in a persistent vegetative state, was completely dependent on staff for mobility and required two-person assistance for rolling side to side. During incontinence care, a CNA attempted to roll the resident alone, resulting in the resident falling from the bed and sustaining a laceration to the skull that required emergency room treatment and stitches. The CNA admitted to providing care alone because she was unable to find another staff member to assist, despite knowing the resident's care plan required two staff for such tasks. Another resident, also in a vegetative state with multiple medical conditions and dependent on staff for all activities of daily living, experienced a similar incident. While being cleaned, the resident was turned by a single CNA, contrary to the care plan that required two staff and the use of a mechanical lift for transfers. The resident fell from the bed, sustaining minor injuries including excoriations and a small hematoma. The CNA involved confirmed she did not wait for another staff member to assist, as required by the care plan.
Failure to Honor Resident's Right to Unrestricted Visitation
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of her choosing at the time of her choosing, resulting in restricted family visitation for one resident. The resident, who was cognitively intact with a BIMS score of 15, had a family member who regularly visited during evening and nighttime hours to ensure her safety and assist with her needs. The family member reported that he was told by staff he could no longer visit at night due to the presence of a roommate, despite there being no complaints from the roommate and no documentation of any disruptive behavior. The facility posted recommended visiting hours and staff informed the family member that he would not be allowed to visit outside these hours, at one point threatening to call the police if he did not leave. Interviews with staff, including the administrator, DON, LPN, CNA, and social services, revealed inconsistent understanding and communication regarding visitation policies. While some staff stated that 24-hour visitation was allowed with recommended hours, others enforced restrictions specifically against the family member's nighttime visits. There was no evidence in the resident's records of any issues caused by the family member, and the roommate had not raised any concerns. The facility did not have a formal visitation policy in place at the time of the incident.
Failure to Maintain Homelike Environment Due to Improper Disposal of Soiled Briefs
Penalty
Summary
Facility staff failed to maintain a homelike environment for one resident who was always incontinent of bowel and bladder and had significant medical conditions, including a vegetative state and acute respiratory failure. Observations revealed that soiled briefs saturated with urine were disposed of in the resident's room trash can, resulting in a noticeable urine odor. Multiple staff interviews confirmed that nursing assistants had disposed of soiled briefs in the resident's trash can instead of the soiled utility room, as expected. Some staff members were unaware of the proper disposal procedure, and at least one CNA stated she had not been trained to remove soiled briefs from the room during her orientation. Family members and housekeeping staff also reported noticing the improper disposal of soiled briefs and the resulting odors. The facility's staffing coordinator acknowledged that while incontinence care competencies were provided, they did not specifically address the disposal of briefs. The Director of Nursing and the Administrator both stated that soiled briefs should be disposed of in the soiled utility room, but there was no homelike environment policy in place at the time of the incident.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an allegation of an injury of unknown origin for one resident. The facility's policy required the Nursing Home Administrator or designee to investigate all allegations and interview all persons involved or with knowledge of the occurrence. The resident in question was totally dependent on staff for all activities of daily living and required two staff members for bed mobility. The resident had a history of chronic left shoulder dislocation and was found to have a fractured humerus or scapula with a dislocated right shoulder, as confirmed by hospital records. The injury was reported to the State Survey Agency in a timely manner, and a five-day follow-up summary was provided. However, the facility's internal investigation did not include interviews with potential witnesses or staff who may have had knowledge of the incident. Interviews with the current DON, Clinical Consultant, and Administrator confirmed that no staff interviews or witness statements were collected as part of the investigation. The current abuse coordinator also stated that her process would include gathering witness statements and interviewing any suspects, but this was not done in this case.
Failure to Obtain Timely Wound Treatment Orders and Provide Pressure Ulcer Care
Penalty
Summary
The facility failed to obtain wound treatment orders and provide appropriate wound care upon admission for a resident who was admitted with a stage 2 pressure ulcer on the sacrum. Upon admission, the wound was documented and a new dressing was applied, but no treatment orders were obtained, and there was no alert charting or documentation of wound care in the medical record. The resident's weekly skin checks continued to note the presence of the sacral wound, but it was not until several days later that a treatment order was finally obtained. During this period, nursing staff reported providing wound care without an order, but did not document these interventions or notify the provider as required. Interviews with facility staff revealed that the wound nurse who initially assessed the resident resigned without obtaining a treatment order, and subsequent staff were unaware of the wound due to lack of communication in nursing reports and absence of alert charting. The wound physician was not made aware of the lack of treatment until after the delay, and the wound was later found to be unstageable and required debridement. The facility's policy required prompt identification and individualized care planning for pressure ulcers, but this was not followed in the resident's case, resulting in a delay in appropriate wound management.
Failure to Provide Consistent Tracheostomy and Respiratory Mouth Care
Penalty
Summary
Surveyors identified that the facility failed to provide safe and appropriate respiratory care, including tracheostomy and respiratory mouth care, for five residents with significant respiratory needs. Each resident had documented diagnoses such as acute or chronic respiratory failure, tracheostomy, ventilator dependence, or persistent vegetative state, and all were dependent on staff for activities of daily living. Care plans and physician orders for these residents specified the need for tracheostomy care and respiratory mouth care at regular intervals, such as every shift or multiple times per day. Record reviews revealed multiple instances where the required respiratory care was not documented as provided. For example, one resident's treatment administration record (TAR) lacked evidence of tracheostomy and mouth care on two out of 24 opportunities, while another resident's TAR showed missing documentation for these interventions on four out of 60 opportunities. Similar deficiencies were found for the other residents, with missed or undocumented care ranging from one to four instances out of 60 possible opportunities per resident. These lapses were confirmed through review of the TARs and were consistent across all five residents reviewed. Interviews with facility staff, including a respiratory therapist and the chief nursing officer, confirmed that the respiratory therapy department was responsible for providing the required care. The findings were reviewed and acknowledged by facility leadership during the exit conference. The deficiency centers on the facility's failure to ensure that respiratory and tracheostomy care was consistently provided and documented according to professional standards and the residents' individualized care plans.
Failure to Complete Post-Fall Assessments and Monitoring per Orders
Penalty
Summary
Two residents experienced deficiencies in care and services following falls, as the facility failed to provide post-fall assessments and monitoring in accordance with physician orders and professional standards. For one resident, after a fall, the physician ordered alert charting every shift for three days. However, nursing staff repeatedly failed to obtain and document current vital signs each shift as required. Instead, they documented outdated vital signs from previous shifts, and this pattern continued even when the resident was placed on alert charting for other symptoms. This failure was acknowledged by the nurse practitioner and confirmed by the chief nursing officer during interviews. For another resident with a history of seizure disorder, ventilator dependence, and persistent vegetative state, the facility did not provide evidence of appropriate monitoring and assessment after a fall that included seizure activity. The resident was found on the floor experiencing a seizure, and staff were unable to obtain a blood pressure reading on the arms due to the severity of the seizure. The clinical record lacked documentation of vital signs, clinical assessments, and seizure monitoring for the day following the incident on two nursing shifts. The facility's own policy required heightened observation and documentation of objective data, including vital signs, for residents placed on alert charting after incidents such as falls. Despite this, the required assessments and documentation were not completed for both residents, as confirmed by staff interviews and record review.
Failure to Obtain and Document Ordered Laboratory Tests for Seizure Medications
Penalty
Summary
The facility failed to obtain and document laboratory services as ordered by providers for two residents with seizure disorders. One resident was admitted with a diagnosis of seizure disorder and had active physician orders for Phenobarbital and Keppra levels to be drawn every six months starting on a specified date. Review of the clinical record showed that the required lab results for that date were absent, and this was confirmed by the Chief Nursing Officer (CNO) during an interview. Another resident, also with a seizure disorder and additional complex medical needs, had physician orders for Phenobarbital and Keppra levels to be drawn every six months. Although the lab draw was scheduled, records indicated that the labs were drawn three days later, and only the Phenobarbital result was eventually uploaded into the clinical record. There was no evidence that the Keppra level was obtained, and the available lab result was not reviewed by the nurse practitioner until more than three and a half months after the draw. These findings were confirmed by facility staff and during the exit conference.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for five residents. Resident 85's room had a privacy curtain that was partially detached from the track and had broken ends. Resident 90's room had reddish stains on the ceiling and a large water stain on the privacy curtain, which was also partially detached and broken. Both observations were confirmed by the Manager of Housekeeping (MH). Resident 25's room was observed to have trash on the floor, a towel under the bed, dark marks under the bed and ventilation system, and a windowsill cluttered with spoons, medical supplies, and a landline phone covered in beard/hair trimmings. The air conditioning unit and television stand were covered in dust and stains. These observations were confirmed by the MH. Resident 40's room had a privacy curtain with multiple spatter stains, damaged netting, and large holes, along with brown spatter stains on the ceiling and under the bed. These issues were also confirmed by the MH. Resident 98's room had red spatter marks on the ceiling and a partially detached privacy curtain with broken ends. The MH confirmed these observations. Interviews with the MH and the Maintenance Director revealed a lack of communication between housekeeping and maintenance regarding environmental issues. The Director of Nursing (DON) stated that environmental checks on residents' rooms were completed once a week, but the deficiencies observed indicate that these checks were not effective in maintaining a homelike environment for the residents.
Incorrect MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident reviewed for MDS assessments. Specifically, the discharge MDS for the resident, with an Assessment Reference Date (ARD) of 01/23/24, was incorrectly coded as a discharge to hospital when it should have been coded as a discharge to home/community. The resident's progress notes indicated a planned discharge home, not to a hospital. During an interview, the MDS Coordinator confirmed the incorrect coding and noted that the facility did not have a specific policy for following the MDS, relying instead on the MDS manual for coding.
Failure to Provide Advance Notice and Ensure Resident Participation in Care Plan Meetings
Penalty
Summary
The facility failed to provide advance notice of care plan meetings to Resident 16 and did not ensure Resident 25 was invited to participate in his quarterly care plan meeting. Resident 16, who was cognitively intact with a BIMS score of 14 out of 15, reported that the facility conducted a care conference in her room without prior notice. The review of her care conference progress notes confirmed the absence of advance notice documentation. Similarly, Resident 25, who had a BIMS score of 15 out of 15, stated he was not invited to his care conference. The review of his care conference progress notes indicated his last participation was in November, but there was no evidence of his participation in the February quarterly care conference. During interviews, the Social Services Director (SSD) acknowledged that care conferences should be scheduled with advance notice and that the facility staff did not document the residents' invitations in the EMR. The Director of Nursing (DON) also confirmed that residents should have been given advance notice and allowed to participate in their care conferences. The facility's policy required care plan meetings to be held at least quarterly with advance notice to residents and their representatives to promote participation, which was not adhered to in these cases.
Failure to Reweigh Resident After Significant Weight Loss
Penalty
Summary
The facility failed to obtain a reweigh within 48 hours after a significant weight loss of 26.3 pounds for a resident who was dependent on tube feeding. The resident, who had multiple diagnoses including gastroesophageal reflux disease, enterocolitis due to clostridium difficile, Parkinson's disease, tracheostomy, ventilator dependence, and dysphagia, experienced a weight drop from 203 pounds to 176.5 pounds over a period of approximately two months. Despite the facility's policy requiring reweighs within 48 hours of significant weight changes, this was not done, and the dietician was not informed of the weight loss in a timely manner. The resident's feeding formula was changed multiple times due to intolerance, and the resident continued to receive tube feeding and liquid protein supplements. However, the resident experienced vomiting and had a distended abdomen, leading to orders to hold tube feeding temporarily. Interviews with staff revealed that the significant weight loss was not promptly addressed, and there was no documentation of family notification regarding the weight loss. The physician's progress note indicated that the resident's weight loss was due to multiple factors, including respiratory failure, advanced Parkinson's disease, and severe gastroparesis, and that the resident was receiving the maximum amount of nutrition tolerable.
Failure to Ensure Timely Pain Medication Delivery
Penalty
Summary
The facility failed to ensure timely delivery of narcotic pain medications and did not offer additional non-pharmacy interventions for a resident with chronic pain, resulting in multiple missed doses and unresolved pain. The facility's policy on medication administration did not address the ordering process for controlled substances or procedures for pharmacy delivery issues. The resident, who was cognitively intact and had a history of chronic pain, polyneuropathy, anxiety disorder, major depression, and post-traumatic stress disorder, reported frequent lapses in receiving pain medication and was not provided with alternative pain management options during these lapses. The resident's care plan included administering analgesia as per orders and evaluating the effectiveness of pain interventions but failed to include non-pharmacy interventions. The resident experienced multiple instances where pain medication was not administered, and alternative medications like Tylenol or Ibuprofen were not offered. The resident reported severe pain and anxiety due to the lack of timely pain management, which was exacerbated by a rare lung disease and an abscessed tooth. Interviews with staff revealed issues with insurance coverage for the medications and a lack of awareness about the pharmacy's delivery cutoff time. The pharmacy director confirmed that orders placed after 1:00 PM would be delivered the following day, contributing to the delays. The resident's pain management was further compromised by the facility's failure to reorder medications promptly and the pharmacy's practice of sending limited quantities of pain medication at a time.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to ensure that trauma survivors received trauma-informed, culturally competent care, which led to potential re-traumatization for two residents. Resident 63, who was admitted with diagnoses including type two diabetes mellitus, Parkinson's disease, and PTSD, had a care plan that did not identify any specific triggers related to PTSD or how to address them. The care plan also failed to address the effects of trauma on the resident's mental, physical, social, emotional, and spiritual well-being. Despite being cognitively intact, as indicated by a BIMS score of 15 out of 15, the resident's care plan lacked a trauma-informed care approach. Similarly, Resident 110, who was admitted with diagnoses including aphasia, cognitive communication deficit, and PTSD, had a care plan that did not identify any specific triggers related to trauma or how to address them. The resident, who was severely cognitively impaired with a BIMS score of zero out of 15, also had a care plan that failed to address the effects of trauma on their well-being. The Director of Nursing confirmed that the care plans for both residents were inadequate as they did not identify the triggers for either resident, despite the facility's policy to provide trauma-informed care.
Failure to Ensure Timely Delivery of Pain Medications
Penalty
Summary
The facility failed to ensure timely delivery of pain medications for a resident (R73) with chronic pain, resulting in unresolved pain. The facility did not have a policy on ordering medications, specifically controlled substances, and did not collaborate effectively with the pharmacy to ensure a process was in place for ordering these medications. This led to multiple missed doses of Oxycodone for R73, as documented in the Medication Administration Record (MAR) and confirmed by interviews with the resident and staff. R73, who was cognitively intact with a BIMS score of 15 out of 15, reported frequently going without pain medications because the nurses did not order them in a timely manner. The resident's electronic medical record (EMR) showed multiple one-time orders for Oxycodone, but there were several instances where the medication was not administered as prescribed. The resident expressed that the facility staff told her the issue was due to insurance not paying for the medication, which was contradicted by the Director of Nursing (DON). Interviews with various staff members, including LPNs and the Director of Quality at the pharmacy provider, revealed inconsistencies in the process of ordering and delivering controlled substances. The pharmacy had a cutoff time for same-day delivery, which was not communicated effectively to the nursing staff. Additionally, there were issues with obtaining new prescriptions and accessing the onsite locked supply of narcotics. These communication and procedural failures contributed to the resident's unresolved pain and distress.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 512 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wilmington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Coral Springs Rehab & Healthcare | 2 mi | ★★★★★ | 8 | 0 |
| Pike Creek Nursing & Rehabilitation Center | 2.1 mi | ★★★★★ | 6 | 0 |
| Excelcare At Newark Llc | 2.4 mi | ★★★★★ | 12 | 1 |
| Regal Heights Healthcare & Rehab Center | 2.5 mi | ★★★★★ | 3 | 0 |
| Willowbrooke Court At Cokesbury Village | 3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Cadia Rehabilitation Pike Creek.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.