Facility profile · CCN 085033
Pike Creek Nursing & Rehabilitation Center
97 federal citations on record , including 3 at the Immediate Jeopardy level, and 4 federal enforcement actions totaling $484,596.
Record summary
Federal record · Q1 202697
Total citations
87
Last 3 years
6
Actual harm+
4
Federal penalties
$484,596
Total fines
1
Overall ★ rating
Most common violation categories here
Most common F-tags at this facility
Citation history
97 on record| Survey | F-Tag | Violation | Severity | Source |
|---|---|---|---|---|
| Aug 13, 2025 | F732 | Post nurse staffing information every day. | C | Complaint |
| Aug 13, 2025 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint |
| Aug 13, 2025 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Complaint |
| Aug 13, 2025 | F550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | E | Complaint |
| Sep 10, 2024 | F947 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | D | Complaint |
| Sep 10, 2024 | F941 | Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | E | Complaint |
| Sep 10, 2024 | F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | Complaint |
| Sep 10, 2024 | F761 | 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. | D | Complaint |
| Sep 10, 2024 | F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Complaint |
| Sep 10, 2024 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Complaint |
| Sep 10, 2024 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | Complaint |
| Sep 10, 2024 | F585 | 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. | D | Complaint |
| Sep 10, 2024 | F580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | Complaint |
| Sep 10, 2024 | F552 | Ensure that residents are fully informed and understand their health status, care and treatments. | D | Complaint |
| Sep 10, 2024 | F949 | Provide behavior health training consistent with the requirements and as determined by a facility assessment. | E | Complaint |
| Sep 10, 2024 | F946 | Provide training in compliance and ethics. | E | Complaint |
| Sep 10, 2024 | F944 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. | E | Complaint |
| Sep 10, 2024 | F867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | D | Complaint |
| Sep 10, 2024 | F804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E | Complaint |
| Sep 10, 2024 | F760 | Ensure that residents are free from significant medication errors. | J | Complaint |
| Sep 10, 2024 | F726 | 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. | J | Complaint |
| Sep 10, 2024 | F691 | Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | D | Complaint |
| Sep 10, 2024 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Complaint |
| Sep 10, 2024 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Complaint |
| Sep 10, 2024 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint |
| Sep 10, 2024 | F943 | Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | D | Standard |
| Sep 10, 2024 | F887 | 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. | D | Standard |
| Sep 10, 2024 | F883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D | Standard |
| Sep 10, 2024 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Standard |
| Sep 10, 2024 | F806 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | D | Standard |
| Sep 10, 2024 | F800 | Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | E | Standard |
| Sep 10, 2024 | F791 | Provide or obtain dental services for each resident. | D | Standard |
| Sep 10, 2024 | F756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D | Standard |
| Sep 10, 2024 | F730 | Observe each nurse aide's job performance and give regular training. | D | Standard |
| Sep 10, 2024 | F697 | Provide safe, appropriate pain management for a resident who requires such services. | D | Standard |
| Sep 10, 2024 | F695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Standard |
| Sep 10, 2024 | F690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | E | Standard |
| Sep 10, 2024 | F688 | 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. | D | Standard |
| Sep 10, 2024 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E | Standard |
| Sep 10, 2024 | F550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | Standard |
| Sep 25, 2023 | F760 | Ensure that residents are free from significant medication errors. | D | Complaint |
| Sep 25, 2023 | F679 | Provide activities to meet all resident's needs. | D | Complaint |
| Sep 25, 2023 | F580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | Complaint |
| Sep 25, 2023 | F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | Complaint |
| Sep 25, 2023 | F835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | F | Complaint |
| Sep 25, 2023 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Complaint |
| Sep 25, 2023 | F804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E | Complaint |
| Sep 25, 2023 | F803 | 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. | C | Complaint |
| Sep 25, 2023 | F773 | Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | D | Complaint |
| Sep 25, 2023 | F761 | 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. | D | Complaint |
| Sep 25, 2023 | F756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | F | Complaint |
| Sep 25, 2023 | F732 | Post nurse staffing information every day. | C | Complaint |
| Sep 25, 2023 | F726 | 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. | E | Complaint |
| Sep 25, 2023 | F710 | Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | D | Complaint |
| Sep 25, 2023 | F697 | Provide safe, appropriate pain management for a resident who requires such services. | G | Complaint |
| Sep 25, 2023 | F690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | Complaint |
| Sep 25, 2023 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G | Complaint |
| Sep 25, 2023 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | H | Complaint |
| Sep 25, 2023 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | E | Complaint |
| Sep 25, 2023 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | E | Complaint |
| Sep 25, 2023 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Complaint |
| Sep 25, 2023 | F655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D | Complaint |
| Sep 25, 2023 | F641 | Ensure each resident receives an accurate assessment. | D | Complaint |
| Sep 25, 2023 | F610 | Respond appropriately to all alleged violations. | D | Complaint |
| Sep 25, 2023 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint |
| Sep 25, 2023 | F607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | C | Complaint |
| Sep 25, 2023 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | Complaint |
| Sep 25, 2023 | F944 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. | F | Standard |
| Sep 25, 2023 | F943 | Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | F | Standard |
| Sep 25, 2023 | F887 | 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. | D | Standard |
| Sep 25, 2023 | F880 | Provide and implement an infection prevention and control program. | J | Standard |
| Sep 25, 2023 | F868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | E | Standard |
| Sep 25, 2023 | F867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | F | Standard |
| Sep 25, 2023 | F849 | 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. | E | Standard |
| Sep 25, 2023 | F843 | 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. | E | Standard |
| Sep 25, 2023 | F758 | 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. | D | Standard |
| Sep 25, 2023 | F730 | Observe each nurse aide's job performance and give regular training. | E | Standard |
| Sep 25, 2023 | F725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | E | Standard |
| Sep 25, 2023 | F698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D | Standard |
| Sep 25, 2023 | F695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Standard |
| Sep 25, 2023 | F692 | Provide enough food/fluids to maintain a resident's health. | D | Standard |
| Sep 25, 2023 | F645 | PASARR screening for Mental disorders or Intellectual Disabilities | D | Standard |
| Sep 25, 2023 | F644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | D | Standard |
| Sep 25, 2023 | F623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D | Standard |
| Sep 25, 2023 | F585 | 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. | F | Standard |
| Sep 25, 2023 | F578 | 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. | E | Standard |
| Sep 25, 2023 | F577 | Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | C | Standard |
| Apr 13, 2023 | F745 | Provide medically-related social services to help each resident achieve the highest possible quality of life. | D | Complaint |
| Apr 13, 2023 | F561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | E | Complaint |
| May 12, 2022 | F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | B | Standard |
| May 12, 2022 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Standard |
| May 12, 2022 | F810 | Provide special eating equipment and utensils for residents who need them and appropriate assistance. | D | Standard |
| May 12, 2022 | F806 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | D | Standard |
| May 12, 2022 | F761 | 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. | D | Standard |
| May 12, 2022 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Standard |
| May 12, 2022 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Standard |
| May 12, 2022 | F558 | Reasonably accommodate the needs and preferences of each resident. | D | Standard |
Federal enforcement history
Federal regulators have imposed 4 enforcement actions against this facility, including 2 civil money penalties totaling $484,596 and 2 payment-denial actions spanning 178 days.
| Date | Type | Fine | Payment denial |
|---|---|---|---|
| Sep 10, 2024 | Fine | $221,208 | — |
| Sep 10, 2024 | Payment Denial | — | Oct 17, 2024 · 64 days |
| Sep 25, 2023 | Fine | $263,388 | — |
| Sep 25, 2023 | Payment Denial | — | Nov 14, 2023 · 114 days |
About this record
A citation is a finding by a state survey team working under federal contract. It is not a court
judgment. The description above is drawn verbatim from federal public datasets. Facilities have
the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.
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