Pike Creek Nursing: Care Plan Deficiencies - DE
Inspectors discovered the missing documentation on August 6 during a complaint investigation at the Limestone Road facility. When they requested the hospice care plan for Resident 110, who was receiving end-of-life services for chronic heart failure, staff directed them to a binder that was supposed to contain the critical documents.
The binder wasn't even at the nurses' station initially. When staff finally located it, inspectors found it completely empty.
Licensed practical nurse E32 had told inspectors earlier that morning that nursing staff could access hospice care plans through the resident's hospice binder. But when the surveyor requested Resident 110's binder at 11:24 AM, no such documentation existed.
Social worker E10 seemed surprised by the missing paperwork. "That is usually found in the hospice binder," E10 told inspectors during a 12:25 PM interview. After reviewing the empty binder together with the surveyor, E10 shifted explanations: "We use our own facility care plan, which should include the hospice care plan."
That backup system had failed too. Inspectors reviewed Resident 110's comprehensive care plan generated by the facility and found no evidence that hospice care requirements had been incorporated. The facility hadn't collaborated with hospice staff to ensure the resident's end-of-life needs and interventions were properly documented.
Resident 110's facility care plan acknowledged the terminal diagnosis, stating the resident "is receiving hospice services and is not expected to improve in condition for diagnosis of CHF." The goal was listed as keeping the resident "as comfortable as possible through review period." But the only intervention listed was "See Hospice plan of care" — the very document that didn't exist in accessible form.
Director of nursing E3 confirmed the facility's responsibility for maintaining current hospice documentation when interviewed at 12:40 PM. "The hospice nurses usually update the binder, and then we make changes as needed," E3 explained, "but I see the binder is missing information, so that should have been addressed."
The missing documentation meant nursing staff lacked access to up-to-date goals and interventions specifically designed for Resident 110's hospice care. Federal regulations require nursing homes to coordinate with hospice providers to ensure comprehensive care planning for terminally ill residents.
Pike Creek's hospice care planning failures extended beyond simple paperwork problems. The facility had created a system where staff were directed to reference documents that didn't exist, potentially compromising care for residents in their final days.
The inspection revealed a breakdown in communication between the facility and its hospice partners. While hospice nurses were apparently responsible for updating the binders, facility staff had no backup system to ensure the critical information remained accessible to bedside caregivers.
During the exit conference on August 13, inspectors presented their findings to nursing home administrator E1, director of clinical services E2, and director of nursing E3. The facility received a citation for failing to ensure hospice care plans were available and integrated into comprehensive care planning.
The violation carried a "minimal harm or potential for actual harm" designation, affecting few residents. But for families trusting Pike Creek to provide dignified end-of-life care, the missing documentation represented a fundamental failure in coordinating hospice services.
Resident 110's case illustrated how administrative oversights can compromise care for the facility's most vulnerable patients — those spending their final days under Pike Creek's supervision, dependent on staff having immediate access to specialized comfort care protocols that simply weren't there when inspectors came looking.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pike Creek Nursing & Rehabilitation Center from 2025-08-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
PIKE CREEK NURSING & REHABILITATION CENTER in WILMINGTON, DE was cited for violations during a health inspection on August 13, 2025.
Inspectors discovered the missing documentation on August 6 during a complaint investigation at the Limestone Road facility.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.