Cycle 1
Health 2024-09-10 · Fire 2024-09-10
30 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Wilmington, DE
Pike Creek Nursing & Rehabilitation Center
1-star overall rating with 1-star inspections with Special Focus status with $484,596 in total fines with 30 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
5651 Limestone Road, Wilmington, DE
(302) 239-8583
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
177
Certified beds
Average residents
157
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifeworks Rehab
Operator or chain grouping
Approved since
1988-08-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
59 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.58
Registered nurse staffing · state 1.03 · national 0.68
LPN hours / resident day
1.12
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
2.09
Nurse aide staffing · state 2.47 · national 2.35
Total nurse hours
3.79
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.70
RN + LPN hours · state 2.04 · national 1.54
Weekend hours
3.32
Weekend nurse staffing · state 4.04 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.72 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.15 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.57
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
71%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
67%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,281
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.67
Baseline 16.03% · Performance 19.73% · Measure score 3.67 · Achievement 3.67 · Improvement 0
Healthcare-associated infections
0
Baseline 6.50% · Performance 8.00% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 26.83% · Performance 91.00% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.30
Baseline 3.57 hours · Performance 4.02 hours · Measure score 3.30 · Achievement 3.30 · Improvement 1.51
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.51% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 337 · Observed rate 10.98% · Lower 95% interval 8.04% |
| Discharge to community | 61.33% |
50.57%
10.8 pts better
|
Better than the National Rate · Eligible stays 327 · Observed rate 50.15% · Lower 95% interval 54.94% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.78% |
95.27%
2.5 pts better
|
Numerator 132 · Denominator 135 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 135 |
| Discharge self-care score | 63.16% |
53.69%
9.5 pts better
|
Numerator 60 · Denominator 95 |
| Discharge mobility score | 60% |
50.94%
9.1 pts better
|
Numerator 57 · Denominator 95 |
| Pressure ulcers or injuries, new or worsened | 2.22% |
2.29%
0.1 pts better
|
Numerator 3 · Denominator 135 · Adjusted rate 2.3% |
| Healthcare-associated infections requiring hospitalization | 8% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 170 · Observed rate 9.41% · Lower 95% interval 5.17% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 152 |
| Staff flu vaccination coverage | 40.61% |
42%
1.4 pts worse
|
Numerator 93 · Denominator 229 |
| Discharge function score | 58.95% |
56.45%
2.5 pts better
|
Numerator 56 · Denominator 95 |
| Transfer of health information to provider | 97.56% |
95.95%
1.6 pts better
|
Numerator 40 · Denominator 41 |
| Transfer of health information to patient | 98.55% |
96.28%
2.3 pts better
|
Numerator 68 · Denominator 69 |
| Resident COVID-19 vaccinations up to date | 38.46% |
25.2%
13.3 pts better
|
Numerator 10 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.8
0.1 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.9 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.4
0.6 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.0 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.8% |
95.7%
1.9 pts worse
|
93.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 88.8% · Q2 100.0% · Q3 98.0% · Q4 89.3% · 4Q avg 93.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.4% |
97.4%
1 pts better
|
95.5%
2.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
3.2%
1.2 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.8% · Q3 2.0% · Q4 1.8% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 63.8% |
6.5%
57.3 pts worse
|
11.4%
52.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 60.4% · Q2 64.0% · Q3 72.2% · Q4 60.0% · 4Q avg 63.8% |
| Percentage of long-stay residents who lose too much weight | 6.5% |
5.6%
0.9 pts worse
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 6.1% · Q3 6.7% · Q4 8.1% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.4% |
21.1%
3.3 pts worse
|
19.6%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 22.8% · Q3 22.0% · Q4 28.3% · 4Q avg 24.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.9% |
12.0%
4.9 pts worse
|
16.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 17.7% · Q3 18.2% · Q4 15.9% · 4Q avg 16.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.0% |
17.5%
2.5 pts better
|
16.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 21.8% · Q3 12.8% · Q4 10.3% · 4Q avg 15.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.1% |
14.7%
2.6 pts better
|
14.9%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 12.9% · Q3 12.2% · Q4 9.9% · 4Q avg 12.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.7%
0.1 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.8% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
2.0%
About the same
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 2.8% · Q3 0.0% · Q4 0.9% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.3% |
21.6%
3.7 pts worse
|
19.8%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 25.1% · Q3 22.0% · Q4 35.4% · 4Q avg 25.3% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
4.4%
0.1 pts worse
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 6.0% · Q3 2.4% · Q4 2.0% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 41.3% |
83.5%
42.2 pts worse
|
81.7%
40.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 51.0% · Q3 48.6% · Q4 43.4% · 4Q avg 41.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.5% |
11.2%
3.7 pts better
|
12.0%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.5% · Observed 8.0% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
0.9%
0.7 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 1.4% · Q4 1.4% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.4% |
83.1%
7.7 pts worse
|
79.7%
4.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.2% |
21.5%
0.7 pts worse
|
23.9%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.2% · Observed 23.0% · Expected 24.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-25 · Fire 2023-09-25
54 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2022-05-12 · Fire 2022-05-12
13 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-09-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-08
F · Potential for more than minimal harm
2023-09-25
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-09-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-23
E · Potential for more than minimal harm
2022-05-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-27
D · Potential for more than minimal harm
2022-05-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-09-27
D · Potential for more than minimal harm
2022-05-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-09-27
D · Potential for more than minimal harm
2022-05-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-09-27
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-09-26
D · Potential for more than minimal harm
2025-08-13
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-26
D · Potential for more than minimal harm
2025-08-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-26
C · Minimal harm
2025-08-13
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-09-26
J · Immediate jeopardy
2024-09-10
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2024-11-11
J · Immediate jeopardy
2024-09-10
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-11-11
E · Potential for more than minimal harm
2024-09-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-11
E · Potential for more than minimal harm
2024-09-10
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-11-11
E · Potential for more than minimal harm
2024-09-10
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2024-11-11
E · Potential for more than minimal harm
2024-09-10
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-11-11
E · Potential for more than minimal harm
2024-09-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-11
E · Potential for more than minimal harm
2024-09-10
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2024-11-11
E · Potential for more than minimal harm
2024-09-10
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2024-11-11
E · Potential for more than minimal harm
2024-09-10
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2024-11-11
E · Potential for more than minimal harm
2024-09-10
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-09-10
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-09-10
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-09-10
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-09-10
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-09-10
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-09-10
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-09-10
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-09-10
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-09-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-09-10
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-09-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-09-10
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-09-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-09-10
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-09-10
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-09-10
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-09-10
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-09-10
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-09-10
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-09-10
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-09-10
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-09-10
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-09-10
F887 · Infection Control Deficiencies
Health
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.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-09-10
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-09-10
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-11-11
J · Immediate jeopardy
2023-09-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-30
H · Actual harm
2023-09-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-07
G · Actual harm
2023-09-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-30
G · Actual harm
2023-09-25
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-11-30
F · Potential for more than minimal harm
2023-09-25
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2023-11-30
F · Potential for more than minimal harm
2023-09-25
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-01-29
F · Potential for more than minimal harm
2023-09-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-30
F · Potential for more than minimal harm
2023-09-25
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-11-30
F · Potential for more than minimal harm
2023-09-25
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-11-30
F · Potential for more than minimal harm
2023-09-25
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2023-11-30
F · Potential for more than minimal harm
2023-09-25
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2023-11-30
E · Potential for more than minimal harm
2023-09-25
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2023-11-30
E · Potential for more than minimal harm
2023-09-25
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-01-29
E · Potential for more than minimal harm
2023-09-25
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-11-30
E · Potential for more than minimal harm
2023-09-25
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-11-30
E · Potential for more than minimal harm
2023-09-25
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2023-11-30
E · Potential for more than minimal harm
2023-09-25
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-01-29
E · Potential for more than minimal harm
2023-09-25
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-01-29
E · Potential for more than minimal harm
2023-09-25
F843 · Administration Deficiencies
Health
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.
Corrected 2023-11-30
E · Potential for more than minimal harm
2023-09-25
F849 · Administration Deficiencies
Health
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.
Corrected 2024-01-29
E · Potential for more than minimal harm
2023-09-25
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-09-25
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-01-29
D · Potential for more than minimal harm
2023-09-25
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-09-25
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-09-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-09-25
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-09-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-09-25
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-09-25
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-09-25
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-09-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-01-29
D · Potential for more than minimal harm
2023-09-25
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-09-25
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-01-29
D · Potential for more than minimal harm
2023-09-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-09-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-29
D · Potential for more than minimal harm
2023-09-25
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-01-29
D · Potential for more than minimal harm
2023-09-25
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-09-25
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-09-25
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-09-25
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-01-29
D · Potential for more than minimal harm
2023-09-25
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-09-25
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-01-29
D · Potential for more than minimal harm
2023-09-25
F887 · Infection Control Deficiencies
Health
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.
Corrected 2023-11-30
C · Minimal harm
2023-09-25
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2023-11-30
C · Minimal harm
2023-09-25
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-11-30
C · Minimal harm
2023-09-25
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-11-30
C · Minimal harm
2023-09-25
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2023-11-30
E · Potential for more than minimal harm
2023-04-13
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-13
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-05-19
E · Potential for more than minimal harm
2022-05-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-05-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-05-12
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-05-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-05-12
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-05-12
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-05-12
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2022-06-30
B · Minimal harm
2022-05-12
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-06-30
Penalties and ownership
What sits behind the stars
$221,208
2024-09-10
Fine
Fine · fine $221,208
Fine
$0
2024-09-10
Payment Denial
Payment Denial · denial start 2024-10-17 · 64 days
64 day denial
$263,388
2023-09-25
Fine
Fine · fine $263,388
Fine
$0
2023-09-25
Payment Denial
Payment Denial · denial start 2023-11-14 · 114 days
114 day denial
Ownership
Pike Creek SNF Operator Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Glen Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Highland De Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Ib Mimi 2022 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
J & R Family Investments, LLC
5% Or Greater Indirect Ownership Interest · Organization
Jk 2022 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Landau Family Investment Trust
5% Or Greater Indirect Ownership Interest · Organization
Mimi Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Ml Milano 2022 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Panther De Partners LLC
5% Or Greater Indirect Ownership Interest · Organization
Rajchenbach, Moshe
Corporate Officer · Individual
Vh Wpc SNF Operations Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
White, Rebecca
W-2 Managing Employee · Individual
Wpc SNF Operations Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Complete Care At Brackenville LLC
Hockessin, DE
5-star overall rating with 4-star inspections with $16,801 in total fines with 8 recent health deficiencies
#2
Cadia Rehabilitation Pike Creek
Wilmington, DE
3-star overall rating with 3-star inspections with $78,351 in total fines with 11 recent health deficiencies
#3
Willowbrooke Court At Cokesbury Village
Hockessin, DE
5-star overall rating with 4-star inspections with 4 recent health deficiencies
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