Pike Creek Nursing: Resident Dignity Violations - DE
Federal inspectors discovered the problem when they requested the hospice binder for Resident 110, a patient receiving end-of-life care for chronic heart failure. The binder that was supposed to contain the hospice care plan was completely empty.
Licensed practical nurse E32 had told inspectors that nursing staff could access the hospice care plan in the resident's hospice binder. But when inspectors asked to see it at 11:24 AM on August 6, staff couldn't locate the binder at the nurse's station.
When they finally found it, there was nothing inside.
"That is usually found in the hospice binder," social worker E10 told inspectors during a joint review of the empty folder. When no documents materialized, E10 shifted explanations: "We use our own facility care plan, which should include the hospice care plan."
It didn't. Inspectors reviewed Resident 110's comprehensive care plan and found no evidence that the hospice plan had been incorporated. The facility had failed to collaborate with hospice staff to ensure the resident's end-of-life needs were being addressed.
Resident 110's documented care goal was straightforward: "The resident's care needs will be met, and they will be as comfortable as possible through review period." The intervention listed was simply "See Hospice plan of care."
But there was no hospice plan to see.
Director of nursing E3 acknowledged the problem when confronted by inspectors at 12:40 PM. She confirmed that the hospice plan was expected to be kept current and available in the binder for staff reference.
"The hospice nurses usually update the binder, and then we make changes as needed," E3 said. "But I see the binder is missing information, so that should have been addressed."
The missing plan left nursing staff without access to updated goals and interventions specifically designed for Resident 110's hospice care. Federal regulations require nursing homes to coordinate with hospice providers to ensure residents receive appropriate end-of-life care.
Hospice care plans typically contain detailed instructions for pain management, comfort measures, and other interventions tailored to a dying patient's specific needs. Without access to these plans, staff cannot provide the specialized care that hospice patients require.
The facility's hospice care plan stated that Resident 110 was "receiving hospice services and is not expected to improve in condition for diagnosis of CHF." Chronic heart failure patients in hospice care often require specific protocols for managing shortness of breath, fluid retention, and other symptoms that can cause significant discomfort.
The inspection occurred following a complaint, suggesting someone raised concerns about care quality at the facility. Federal inspectors classified the violation as causing minimal harm or potential for actual harm to residents.
Pike Creek Nursing & Rehabilitation Center operates at 5651 Limestone Road in Wilmington. The facility's administrator, director of clinical services, and director of nursing reviewed the findings during an exit conference on August 13.
The missing hospice plan represents a breakdown in the coordination between the nursing home and hospice provider that could leave dying residents without appropriate comfort care. Staff working without current hospice plans cannot ensure they're following the most recent medical orders or comfort measures designed specifically for end-of-life care.
For Resident 110, receiving hospice care for a failing heart, the missing plan meant staff lacked access to the detailed roadmap meant to guide their final days of life.
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.
The binder that was supposed to contain the hospice care plan was completely empty.
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.