Skip to content
ProPublica
Donate
ProPublica
Donate
Nursing Home Inspect > Delaware > New Castle County Data as of October 2024

    Pike Creek Nursing & Rehabilitation Center

    For profit - Corporation  ·  5651 Limestone Road, Wilmington, DE 19808  ·  See home’s Medicare page

    Special Focus Facility Candidate
    Has a history of serious quality issues but has not been formally flagged by the government.
    4.15
    Nurse hours/resident/day
    Reported total nurse staffing hours per resident per day.
    State Average: 4.5
    81.8%
    Nurse turnover
    The percentage of nursing staff who stopped working at the home over a 12-month period.
    State Average: 49.5%
    177
    Certified beds
    Qualifying beds in the certified provider or supplier facility.
    128
    Average residents/day
    Average number of residents based on daily census.
    Direct owners are the layer of ownership closest to the nursing home while indirect owners have a stake in the nursing home but are further removed, like a company that owns the direct owner of a home. All owners listed below are people or companies who have at least a 5% stake in the nursing home. Entities with “managerial control” are those who conduct the day-to-day operations of the nursing home.
    Direct owners
    Pike Creek Snf Operator Holdings Llc (100%)
    Indirect owners
    Glen Holdco Llc
    Highland De Holdings Llc
    Ib Mimi 2022 Family Trust
    J & R Family Investments, Llc
    Jk 2022 Family Trust
    Landau Family Trust
    Mimi Holdco Llc
    Ml Milano 2022 Family Trust
    Panther De Partners Llc
    Vh Wpc Snf Operations Holdings Llc
    Wpc Snf Operations Holdings Llc
    Managerial control
    No information available
    Managing employee(s)
    Rebecca White since Aug, 2023

    Inspection Reports

    67

    total deficiencies

    2

    infection-related deficiencies

    This home violated federal standards protecting residents from the spread of infections.

    Inspection reports document deficiencies, which are nursing homes’ failures to meet care requirements. The Centers for Medicare and Medicaid Services releases the last three standard inspection reports, as well as the last 36 months of complaint and infection-control reports.
    Sep 25, 2023
    Standard report
    44 deficiencies
    (2 infection)

    This report includes a citation for violating federal standards protecting residents from the spread of infections.
    $263,388 Fine
    1 Payment Suspension
    C

     to J
    J
    Full report
    Infection Control Deficiency — F0880
    Failure to: Provide and implement an infection prevention and control program.
    Severity
    Immediate jeopardy to resident health or safety
    Scope
    Few people affected
    Seriousness
    J
    Quality of Life and Care Deficiency — F0684
    Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
    Severity
    Actual harm that is not immediate jeopardy
    Scope
    Some people affected
    Seriousness
    H
    Quality of Life and Care Deficiency — F0689
    Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    Severity
    Actual harm that is not immediate jeopardy
    Scope
    Few people affected
    Seriousness
    G
    Quality of Life and Care Deficiency — F0697
    Failure to: Provide safe, appropriate pain management for a resident who requires such services.
    Severity
    Actual harm that is not immediate jeopardy
    Scope
    Few people affected
    Seriousness
    G
    Resident Rights Deficiency — F0585
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Pharmacy Service Deficiency — F0756
    Failure to: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Nutrition and Dietary Deficiency — F0812
    Failure to: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Administration Deficiency — F0835
    Failure to: Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Administration Deficiency — F0867
    Failure to: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0943
    Failure to: Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Administration Deficiency — F0944
    Failure to: Conduct mandatory training, for all staff, on the facility's Quality Assurance and Performance Improvement Program.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Resident Rights Deficiency — F0578
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Assessment and Care Planning Deficiency — F0657
    Failure to: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Quality of Life and Care Deficiency — F0677
    Failure to: Provide care and assistance to perform activities of daily living for any resident who is unable.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Nursing and Physician Services Deficiency — F0725
    Failure to: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Nursing and Physician Services Deficiency — F0726
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Nursing and Physician Services Deficiency — F0730
    Failure to: Observe each nurse aide's job performance and give regular training.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Nutrition and Dietary Deficiency — F0804
    Failure to: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Administration Deficiency — F0843
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Administration Deficiency — F0849
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Administration Deficiency — F0868
    Failure to: Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
    Failure to: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
    Failure to: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0610
    Failure to: Respond appropriately to all alleged violations.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0623
    Failure to: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0641
    Failure to: Ensure each resident receives an accurate assessment.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0644
    Failure to: Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0645
    Failure to: PASARR screening for Mental disorders or Intellectual Disabilities
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0655
    Failure to: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0656
    Failure to: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0690
    Failure to: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0692
    Failure to: Provide enough food/fluids to maintain a resident's health.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0695
    Failure to: Provide safe and appropriate respiratory care for a resident when needed.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0698
    Failure to: Provide safe, appropriate dialysis care/services for a resident who requires such services.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nursing and Physician Services Deficiency — F0710
    Failure to: Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0758
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0761
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Administration Deficiency — F0773
    Failure to: Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0842
    Failure to: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Infection Control Deficiency — F0887
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0577
    Failure to: Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    Severity
    No actual harm, with potential for minimal harm
    Scope
    Many people affected
    Seriousness
    C
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0607
    Failure to: Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    Severity
    No actual harm, with potential for minimal harm
    Scope
    Many people affected
    Seriousness
    C
    Nursing and Physician Services Deficiency — F0732
    Failure to: Post nurse staffing information every day.
    Severity
    No actual harm, with potential for minimal harm
    Scope
    Many people affected
    Seriousness
    C
    Nutrition and Dietary Deficiency — F0803
    Failure to: 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.
    Severity
    No actual harm, with potential for minimal harm
    Scope
    Many people affected
    Seriousness
    C
    Apr 13, 2023
    Complaint report
    2 deficiencies
    D

     to E
    E
    Full report
    Resident Rights Deficiency — F0561
    Failure to: Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Quality of Life and Care Deficiency — F0745
    Failure to: Provide medically-related social services to help each resident achieve the highest possible quality of life.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    May 12, 2022
    Complaint report
    2 deficiencies
    $8,405 Fine
    D

     to E
    E
    Full report
    Resident Rights Deficiency — F0626
    Failure to: Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0580
    Failure to: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    May 12, 2022
    Standard report
    8 deficiencies
    $8,405 Fine
    B

     to E
    E
    Full report
    Nutrition and Dietary Deficiency — F0812
    Failure to: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0558
    Failure to: Reasonably accommodate the needs and preferences of each resident.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0657
    Failure to: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0684
    Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0761
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nutrition and Dietary Deficiency — F0806
    Failure to: Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nutrition and Dietary Deficiency — F0810
    Failure to: Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0842
    Failure to: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    Severity
    No actual harm, with potential for minimal harm
    Scope
    Some people affected
    Seriousness
    B
    Jun 23, 2021
    Standard report
    11 deficiencies
    D

     to E
    E
    Full report
    Quality of Life and Care Deficiency — F0684
    Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0580
    Failure to: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0607
    Failure to: Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0622
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0641
    Failure to: Ensure each resident receives an accurate assessment.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0657
    Failure to: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0677
    Failure to: Provide care and assistance to perform activities of daily living for any resident who is unable.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0695
    Failure to: Provide safe and appropriate respiratory care for a resident when needed.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nursing and Physician Services Deficiency — F0730
    Failure to: Observe each nurse aide's job performance and give regular training.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0756
    Failure to: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nutrition and Dietary Deficiency — F0812
    Failure to: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D

    Penalties

    $272K

    total fines

    1

    payment suspension

    A nursing home receives a penalty, either a fine or payment suspensions, when it has a serious health citation or fails to fix a citation. Fines may be imposed once per citation or regularly until the nursing home corrects the citation. Fines not associated with inspection reports can include fines for not reporting COVID-19 data or not complying with infection-control requirements. Payment suspensions are when the government stops payments to the nursing home until an issue is fixed. The Centers for Medicare and Medicaid Services releases the last three years of penalty information.
    Sep 25, 2023
    $263,388 fine
    1 Payment Suspension
    May 12, 2022
    $8,405 fine