Cadia Rehabilitation Pike Creek

Inspectors wroteBased 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. [...]

Inspectors wroteBased on record review and interview, it was determined that for one (R1) out of three residents reviewed for reporting of alleged violations, the facility failed to identify and report an allegation of neglect. The facility submitted a State reportable incident for a fall with injury and failed to acknowledge the actual allegation of neglect when a staff person transferred a resident incorrectly, resulting in a fall with significant injury.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure residents either had an advanced directive in place or failed to provide the residents and/or their resident representatives (RR) written information of the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for four of 13 residents (Resident (R) 9, R77, R6, and R161) reviewed for advanced directives out of a total sample of 55 residents. This failure created the potential the residents' wishes would not be followed if the residents were unable to speak for themselves.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure kitchen staff thoroughly cleaned and air-dried pots and pans prior to storage. In addition, the facility failed to ensure staff with facial hair wore a beard guard for facial hair. These failures increased the risk of foodborne illness by allowing wet pots and pans to be stored before fully drying and by failing to cover facial hair. This had the potential to affect 103 of the 152 residents receiving dietary services.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure ordered pressure ulcer treatments were completed and/or newly identified skin changes were reported for three of five sampled residents (Resident (R) 182, R37, and R20) reviewed for pressure ulcers out of a total sample of 55. Failure to complete wound treatments as ordered and report changes in skin integrity placed the residents at increased risk of infection and wound deterioration.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to safeguard controlled medications used in facility stock and failed to safeguard controlled medications and/or ensure the availability of physician ordered medications for two of 55 sampled residents (Resident (R)178 and R5). These failed practices placed residents at risk for medication diversion, unmanaged symptoms, and failure to receive medications as prescribed.

Inspectors wroteBased 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. On 10/14/24 R162 was emergently transferred to the hospital and was diagnosed with an acute subdural hematoma with a left to right shift requiring a craniotomy and intubation while in the hospital resulting in a delay of care. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that two of 10 residents reviewed for accidents (Resident (R) 114 and R90) were provided supervision to prevent accidents. Both residents were planned for two staff for bed mobility and transfer but only one staff provided care. R114 was harmed when injuries from the all required emergecy room treatment with stitches to a laceration to the skull. R90 sustained minimal injuries. Verification of training and binder review confirmed the incident with R114 was corrected 12/3/24 and determined to be past-non compliance. The citation for R90 was a D level finding was verified as corrected on 3/21/24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was not more than a 14-hour gap between the evening meal (dinner) and breakfast the following day for 118 out of 158 residents (40 residents received nutrition via tube feedings). The planned meal gap between dinner and breakfast the following day was 15 hours. The resident group had not approved the 15-hour gap between dinner and breakfast. This created the potential for residents to experience hunger while waiting for breakfast.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner. Specifically, the dish room was in a state of disrepair, the floors lacked regular cleaning, dishware was not clean, there was no garbage can in the handwashing sink area that prevented contamination of one's hands, wiping rag sanitizer solutions were not at the proper concentration, and food was not properly labeled. These failures placed 118 out of 158 residents (40 residents received nutrition via tube feedings) at risk for foodborne illness.

Inspectors wroteBased on observation, interview, review of the pest control contract, pest control service records, and work orders, the facility failed to ensure the kitchen and adjacent cart storage area were free from pests including fruit flies and ants. The facility failed to keep the kitchen clean and to make needed repairs to deter pests as recommended by their pest control provider. This created the potential for the harborage of insects and vermin.

Inspectors wroteBased on observation, interview, and record review, the facility failed to allow family visitation for one out of 49 sampled residents (Resident (R)10). The facility restricted visitation of R10's family member (Family Member (F) 4). This failure violated R10's right as a resident of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a homelike environment was maintained for one resident (Resident (R) 90) out of 49 sampled residents. Facility nursing staff disposed of a soiled brief in R90's trash can which caused urine odor in the resident's room. This had the potential to create odors throughout the facility.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to thoroughly investigate an allegation of an injury of unknown origin for one resident (Resident (R) 101) of 17 residents reviewed for abuse.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to revise a person-centered care plan related to falls for one resident (Resident (R) 141) out of nine residents reviewed for accident. This had the potential for the residents to have injuries related to falls due to care needs not being identified.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to obtain wound treatment orders and provide wound care upon admission to the facility for one of eight residents reviewed for pressure ulcers (Resident (R) 170).

Inspectors wroteBased on observation, record review, and interview, the facility failed to administer medications timely for two of five residents (Resident (R) 41 and R145) reviewed for medication administration out of 49 sampled residents. This had the potential to result in adverse health outcomes.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure a medication error rate of less than five percent during medication administration. The facility had two errors in twenty-six opportunities, due to not properly administering medicated eye drops and not priming an insulin pen. This resulted in a seven percent error rate and affected two (Resident (R) 41 and R64) out of five residents observed. Medication errors have the potential to result in adverse health outcomes.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure one of four sampled residents reviewed for hospitalization (Resident (R) 162) and R162's representative were notified of the reasons in writing for R162's transfer to the hospital on [DATE]. Additionally, there was no evidence that the Ombudsman was notified of the transfer/discharge. This failure placed all residents at risk of not being informed of their appeal rights and process after they are discharged from the facility.

Inspectors wroteBased on observation, interview, and record review, it was determined that for five (R2, R3, R4, R5, and R6) out of five residents reviewed for respiratory care, the facility failed to ensure that respiratory care, including tracheostomy care and respiratory mouth care, was provided consistent with professional standards of practice and the comprehensive person-centered care plan.

Inspectors wroteBased on interview and record review, it was determined that for two (R1 and R3) out of three residents sampled for falls, the facility failed to ensure that each resident received care and services in accordance with physician orders and professional standards of practice for post-fall assessments. For R1, the facility failed to obtain and document current vital signs (VS) every shift after alert charting was initiated for increased monitoring of the resident. For R3, the facility failed to ensure the resident was monitored after a fall which included seizure activity.

Inspectors wrote2. Review of R3's clinical record revealed: 12/17/22 - R3 was admitted to the facility with diagnoses including acute and chronic respiratory failure, seizure disorder, ventilator dependence, and persistent vegetative state. R3 was completely dependent on staff for all activities of daily. 10/24/24 - R3's physician's orders included, Phenobarbital, Keppra Levels every night shift every 6 month(s) starting on the 25th . Lab draw was scheduled for 10/25/24 on the 11-7 shift. R3's clinical records (lab records) documented that the labs were drawn on 10/28/24. 2/12/25 11:00 AM - A review of R3's clinical records failed to show evidence of the antiseizure medications laboratory results from 10/28/24. During an interview, E3 (Unit Manager) stated, I will check for the results. E3 confirmed with the Surveyor that the lab results were not available in R3's clinical record. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment. Specifically, the facility failed to ensure a homelike environment for five of 49 sampled residents (Resident (R) 85, R90, R25, R40, and R98).

Inspectors wroteBased on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment for one of 49 sampled residents (Resident (R) 142) reviewed for MDS assessments. This deficient practice increased the potential for missed opportunities of care or services.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to provide one Resident (R) 16 advance notice of their care plan meetings and ensure one resident (R25) was invited to participate in his quarterly care plan meeting of 49 sampled residents.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to obtain a reweigh within 48 hours after a 26.3-pound weight loss for one of four residents (Resident (R) 104) reviewed for nutrition of 49 sampled residents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure narcotic pain medications were delivered in a timely manner, failed to offer additional non-pharmacy interventions or medications, and recognize there was an issue with pharmacy delivery for one of one resident (Resident (R) 73) reviewed for pain management of 49 sampled residents. This resulted in the resident missing multiple doses of pain medication and unresolved pain.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure that trauma survivors received trauma-informed, culturally competent care accounting for residents' experiences and preferences to avoid triggers (psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening) leading to potential re-traumatization for two of two residents (Resident (R) 63 and R110) of 49 sampled residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to identify issues related to timely delivery of pain medications for one of one resident (Resident (R) 73) reviewed for pain management of 49 sampled residents. The facility also failed to collaborate with the pharmacy to ensure a process was in place for ordering controlled substances. This resulted in R73 having unresolved pain.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on record review and interview, it was determined that for one (R1) out of nineteen residents reviewed for Quality of Care, the facility failed to ensure the provider was consulted for a significant change. R1 had an elevated heart rate, ranging from 120 to 154 beats per minute, intermittently for five days and consistently for sixteen hours prior to R1's 7/1/23 hospitalization with no interventions or notification of the provider.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that R3's care was implemented in accordance with professional standards of practice as evidence by a nurse prepared R3's medications and were administered by another nurse.

Inspectors wroteBased on record review and interview, it was determined that for one (R2) out of nineteen residents reviewed for Quality of Care. R2 was transported to an outpatient medical center at which he did not have an appointment and then waited greater than five hours for a return ride back to the facility missing lunch and medications.

Inspectors wrote2. Review of R1's clinical record revealed: 1/20 2015 - R1 admitted to the facility with diagnoses including but not limited to: chronic respiratory failure with the need for mechanical ventilation (machine to assist breathing) through a tracheostomy (surgical opening in the windpipe that allows air to enter and secretions to be removed), and spastic quadriplegic (a condition that affects all four limbs in which the person has lost control of her entire body but does display stiff, jerky movements stemming from increased muscle tone) cerebral palsy. a. 7/2/23 4:51 PM - E43's (Otolaryngology [ears, nose & throat] MD Hospital Consult note documented, . Shiley in place. CT . the tracheostomy was exchanged for a Bivona flexible tracheostomy secured at 9 cm (centimeters) at the skin. There was immediate improvement . [...]