Cadia Rehabilitation Pike Creek

In the surveyor’s words

From the most serious findings on record at Cadia Rehabilitation Pike Creek, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 1, 2026

  Based on observation, interview, and record review, it was determined that for two (R1and R2) out of three residents reviewed for accident hazards and falls, the facility failed to ensure that R1 and R2 received adequate assistance and supervision to prevent falls to the extent possible. R1, a cognitively impaired and completely dependent resident, sustained a fall on 6/9/26 at 4:15 PM when a staff member used an incorrect mechanical lift and sling to perform a transfer from the wheelchair to the bed. This fall caused R1 to suffer a hematoma to the front of her head, and she was sent emergently to the hospital. R1 was diagnosed with multiple brain bleeds and skull fractures. Due to this failure, an Immediate Jeopardy (IJ) was called at 9: 00 AM on 6/16/26. […]

• Immediate jeopardy, isolatedF684Apr 18, 2025

  Based on observation, interview, record review, and policy review, the facility failed to ensure residents who experienced a change in condition received timely treatment for one of four sampled residents reviewed for a change in condition (Resident (R)162). R162's had a fall at home prior to admission and sustained a subdural hematoma requiring a craniotomy (a surgical procedure where a neurosurgeon makes an opening in the skull to access and remove a blood clot (hematoma) that has formed to relieve pressure on the brain). R162 experienced changes in his condition after a fall he sustained on 10/10/24. […]

• Immediate jeopardy, isolatedF711Oct 17, 2023

  Based on interview and record review, it was determined that for two (R5 and R19) out of four residents reviewed for physician visits, the facility failed to ensure that the physician reviewed R5's total program of care including medications.R5's Eliquis (anticoagulant-medication that works to prevent clotting of blood) was not re-started following R5's outpatient procedure on [DATE]. The facility's failure to ensure the physician/providers had a process to track residents on anticoagulants placed R5 in immediate jeopardy (IJ) of a serious adverse outcome. R5 had chronic atrial fibrillation, which placed him at risk for developing clots; R5 has been prescribed eliquis since [DATE] in order to prevent the development of clots. […]

• Immediate jeopardy, isolatedF760Oct 17, 2023

  Based on interview, record review and review of other facility documentation, it was determined that for one (R4) out of four residents reviewed for medication errors, the facility failed to ensure R4 received the correct dose of NPH (Neutral Protamine [NAME]) insulin on 9/7/23. The facility's failure placed R4 at risk for a serious adverse outcome, hypoglycemia and diabetic coma. An IJ was identified and due to the facility's corrective measures following the incident on 9/7/23 at approximately 5:00 PM this is being cited as past non-compliance with an abatement date of 9/8/23. Findings include: A facility policy Blood Glucose Monitoring last revised 11/12/21, reviewed 1/20/23 documented, It is the policy of Cadia Healthcare to provide safe blood glucose monitoring . […]

• Immediate jeopardy, isolatedF880Feb 23, 2023

  Based on observations, interviews and reviews of clinical records, facility documentation and other sources as indicated, it was determined that the facility failed to maintain an infection prevention and control program to protect the residents against an outbreak of norovirus (a highly contagious infection that can cause a sudden onset of severe vomiting and diarrhea) and they failed to have a system in place to control a contagious disease to residents, staff and visitors. For three (R52, R167 and R417) out of nine sampled residents, the facility failed to actively adhere to contact precautions and hand hygiene among healthcare personnel, residents, and visitors in patient care areas affected by outbreaks of norovirus gastroenteritis, including a process to identify the residents who… […]