Pike Creek Nursing & Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF726Sep 10, 2024

  Based on interview, review of clinical records including two incidents involving significant medication errors and other documentation as indicated, it was determined that for 29 out of 29 licensed nurses reviewed, the facility failed to have a system/process in place to ensure each licensed nurse had competencies and skills sets necessary to care for current residents' needs. - On 7/6/24, E43 (RN) administered another resident's medications to R322, which resulted in a serious adverse outcome. R322 required emergent admission to the ICU for treatment and monitoring. The facility failed to ensure E43 had a medication administration competency and skill set validated during his orientation. […]

• Immediate jeopardy, isolatedF760Sep 10, 2024

  Based on observation, interview, review of clinical records and other documentation as indicated, it was determined that for one (R322) out of three residents reviewed for hospitalization s and three (R22, R33 and R95) out of nine residents reviewed for medication administration, the facility failed to ensure that residents were free of significant medication errors. On [DATE], R322 was administered R144's prescribed medications. As a result, R322 was emergently sent to the hospital requiring treatment and monitoring in the Intensive Care Unit (ICU). The facility's multiple failures involved in this incident had the potential to cause a serious adverse outcome or death to R322 with respect to receiving another resident's multiple blood pressure medications and diabetic medications. […]

• Immediate jeopardy, isolatedF880Sep 25, 2023

  Based on interview and review of facility documentation as indicated, it was determined that the facility failed to implement their infection control program for COVID-19 after a resident on 8/4/23 tested positive and subsequent positives were identified on 8/15/23 and 8/19/23, putting residents at risk for a severe adverse outcome. On 8/22/23 at 4:40 PM, an Immediate Jeopardy (IJ) was called. Based on review of the facility's corrective actions, the IJ was abated on 8/23/23 at 3:00 PM. Additionally, the facility failed to maintain laundry services in a sanitary manner. Findings include: The facility's policy and procedure entitled COVID-19, dated 5/10/23, stated, . 5. Containment/Management: a. […]

• Immediate jeopardy, isolatedF678Jan 25, 2021

  Based on review of clinical records, interviews, review of other facility documentation, and the Emergency Medical Services (EMS) report, it was determined that for one (R1) out of three sampled residents reviewed for CPR, the facility failed to provide basic life support, including CPR, to R1 who had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at approximately 2:30 PM, R1 was found unresponsive and was assessed to be without a pulse or respirations and R1 had fixed (non-responsive) pupils. Despite this, the facility failed to call 911 until [DATE] at 3:50 PM (one hour and 20 minutes later). EMS staff arrived at the facility at 4:00 PM and initiated CPR at 4:01 PM. R1 was pronounced as deceased by EMS at 4:40 PM on [DATE]. […]

• Immediate jeopardy, isolatedF726Jan 25, 2021

  Based on interviews, review of a clinical record, and facility and staff agency (SA) documentation as indicated, it was determined that the facility failed to have a system in place to ensure that four (E9, E12, E23 and E24) out of four (4) licensed agency nurses working in the facility during the year of 2020 were oriented to the facility's practices, trained, and/or had competency and skills assessed prior to providing resident care. For E12, a newly hired agency LPN, the facility failed to ensure that E12 had specific orientation and training to facility practices prior to providing care to residents, which was necessary to care for and to assure the safety of R3, a newly admitted resident. As a result of the facility's failure, R3 had a serious adverse outcome, death. […]