Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hickory Creek At Madison during CMS and state inspections, most recent first.
Kitchen sanitation and food storage deficiencies: Surveyors observed repeated unsanitary conditions in the kitchen, including food debris and buildup on the reach-in refrigerator/freezer, ovens, griddle, condiment shelf, food processor, dish machine doors, and floor under the stove. An uncooked pork loin and later a turkey breast were stored in the bottom of the refrigerator without a drip pan, and a dietary staff member stated each shift cleaned up at the end of their shift while no cleaning schedule was in place.
Insulin pens were found improperly labeled and an expired pen remained in storage. An LPN and DON identified that a resident’s Novolog, Lantus, and another resident’s Basaglar lacked proper pharmacy/order labeling, while unused Humalog pens from home were still in the refrigerator. Another resident’s Toujeo pen was kept and administered after its open-date expiration, despite staff stating insulin storage should be checked for unused medication.
Incorrect Weekly Skin Assessment Documentation: A resident with multiple chronic conditions, including malnutrition, dysphagia, muscle weakness, and skin atrophy, had a documented wound on the right buttock at admission and later another open area on the coccyx. Multiple weekly skin and vital signs assessments were coded as having no open areas despite the wound being present, and the DON confirmed several assessments were entered incorrectly.
The facility failed to maintain oxygen concentrator filters for three residents, leading to deficiencies in respiratory care. A resident's filters were covered with a white powdery substance, and the humidifier bottle was on the floor. Another resident's filters were similarly uncleaned, and they were hospitalized with a UTI and pneumonia. A third resident's filter had white chunks, and the privacy curtain obstructed it. Despite orders to clean the equipment, the facility did not adhere to its Oxygen Therapy policy.
The facility failed to document a resident's skin assessment and implement a treatment order for a skin tear upon re-admission. A resident with multiple diagnoses, including multiple myeloma and diabetes, was readmitted with an abrasion and an open area. The resident's left arm had multiple mepilexes, and a new skin tear was noted from the adhesive. The clinical record lacked documentation of an assessment of the skin under the mepilexes or the implementation of a treatment order for the skin tear.
Kitchen sanitation and food storage deficiencies
Penalty
Summary
The facility failed to ensure the kitchen was clean and sanitary during 3 of 3 kitchen observations. On 9/14/25 at 9:30 a.m., surveyors observed both the reach-in refrigerator and reach-in freezer with food particles on the bottom inside, streaks and brown spots on the doors, a gallon jar of buttermilk salad dressing with a loose lid and streaks running down the outside, an uncooked pork loin sitting in water directly on the bottom of the refrigerator without a pan, a food processor lid with beige particles and a base with crumbs, a condiment shelf with brown and yellow food particles and white splatters, a left oven with brown and black rod-shaped particles and debris, and a floor under the stove with dirt, crumbs, and debris. During a lunch observation at 11:40 a.m., the previously observed issues remained, the griddle had buildup, the area in front of it had heavy black charred substance and grease, and the uncooked pork roast still sat directly on the bottom of the refrigerator without a drip pan. On 9/18/25 at 10:45 a.m., the left oven still had heavy debris, the floor under the stove still had dirt and food crumbs, the reach-in refrigerator and freezer still had heavy streaks and soil on the door vents, and there was a heavy white/gray buildup along the top edges of the dish machine doors. The buttermilk jar had a moderate buildup around the lid edges, and a turkey breast was defrosting in the bottom of the refrigerator with water extending out about 1 inch and no drip pan under the meat. The review of the Summer cycle menus on 9/18/25 at 11:10 a.m. failed to indicate rice had been served at any meal. The dietary staff member stated each shift cleaned up at the end of their shift and there was no cleaning schedule at the time, while the ED stated she had not seen the issues identified and felt the staff were doing the best they could with new staff in the kitchen.
Insulin Pens Found Unlabeled and Expired in Medication Storage
Penalty
Summary
The facility failed to ensure insulin pens were properly labeled with pharmacy and physician order information and failed to remove unused or expired insulin pens from medication storage. During observation of the medication carts and refrigerator, Resident 18’s Novolog pen had no pharmacy or order label on the packaging, and a box containing five unopened Humalog pens for Resident 18 was found in the medication room refrigerator even though staff stated the resident had brought the medication from home at admission and it would not be used. Resident 18’s record showed a diagnosis of type 2 diabetes mellitus with hyperglycemia and documentation of multiple insulin injections in the prior 7 days, but the September 2025 MAR lacked documentation of a physician’s order or administration of Novolog. Staff stated insulin pens should be checked for expiration dates and proper labeling, and that unused medications in the refrigerator should be discarded. Resident 18’s Lantus Solostar pen and Resident 24’s Basaglar kwikpen were both found in plastic bags in the medication cart drawer with handwritten resident names but no pharmacy labels. Resident 18 had a physician’s order for daily Lantus, and the MAR showed the medication was administered on multiple dates after pharmacy delivery. Resident 24 was cognitively intact, had a diagnosis of type 2 diabetes mellitus with diabetic neuropathy, and had a physician’s order for Basaglar twice daily; the MAR showed ongoing administration through the observation period. Resident 14’s Toujeo U-300 pen had an open date of 8/6/25 and was observed on 9/16/25 even though it had expired 28 days after opening on 9/4/25; the MAR showed the resident continued to receive the medication after expiration. The DON stated the night shift nurse was supposed to check the refrigerator for unused medication.
Incorrect Weekly Skin Assessment Documentation
Penalty
Summary
The facility failed to ensure the accuracy of weekly skin assessments for one resident whose record was reviewed. The resident had diagnoses including chronic atrial fibrillation, essential hypertension, neuromuscular dysfunction of the bladder, vitamin D deficiency, atrophic disorder of the skin, tremor, unspecified protein-calorie malnutrition, dysphagia, and muscle weakness. The care plan identified the resident as being at risk for skin breakdown due to sensory impairment, occasional moisture, chairfast status, inability to bear weight, limited ability to change body position, inadequate intake, and high risk for friction and shearing, with interventions to assess and document skin condition weekly and as needed and notify the physician of abnormal findings. The admission assessment documented a wound on the resident’s right buttock measuring 1 cm by 1 cm with no depth. However, the weekly skin and vital signs assessments between 6/3/25 and 9/15/25 were coded incorrectly on multiple occasions as showing no open areas, including assessments dated 6/3/25, 6/10/25, 6/24/25, 6/30/25, 7/7/25, 7/14/25, 8/25/25, 9/1/25, 9/8/25, and 9/15/25. During observation of wound treatment, the DON described the wound as dime sized with a pink wound bed and edges and noted a larger pink area around the coccyx from a previous healed laceration. The DON later stated the resident had an open area on the right buttock from admission until 7/16/25, then developed another open area on the coccyx on 7/22/25, and that several weekly skin assessments had been coded incorrectly regarding whether an open area was present.
Failure to Maintain Oxygen Concentrator Filters
Penalty
Summary
The facility failed to maintain oxygen concentrator filters for three residents, leading to deficiencies in respiratory care. Resident 16's oxygen concentrator filters were observed to be completely covered with a white powdery substance on multiple occasions, and the humidifier bottle was found on the floor. Despite a physician's order to clean the concentrator and filter weekly, the filters remained uncleaned, and the resident experienced respiratory symptoms, including a sore throat and diminished lung sounds. Resident 29's oxygen concentrator filters were also covered with a white powdery substance, and the resident was admitted to the hospital with a urinary tract infection and pneumonia. The care plan required regular cleaning of the concentrator and filter, but observations indicated this was not done. The DON and LPN acknowledged the issue, noting that the Medical Supply company was responsible for cleaning the filters, but they were not adequately maintained. Resident 21's oxygen concentrator filter had scattered white chunks, and the privacy curtain was obstructing the filter. The resident had a history of chronic respiratory conditions and required continuous oxygen therapy. Despite orders to maintain and clean the oxygen equipment, the filters were not properly maintained, and the resident's lung sounds were diminished. The facility's Oxygen Therapy policy emphasized avoiding contamination of oxygen equipment, but this was not adhered to, contributing to the deficiency.
Failure to Document Skin Assessment and Implement Treatment Order
Penalty
Summary
The facility failed to document a resident's skin assessment and implement a treatment order for a skin tear upon re-admission. Resident B, who had diagnoses including multiple myeloma, diabetes, and anorexia, was readmitted with a 1 cm abrasion to the left shin and an open area below the coccyx. The care plan indicated that the resident was at risk for skin breakdown and required weekly skin assessments and treatments as ordered. However, upon re-admission, the resident's left arm was covered with multiple mepilexes, and a new skin tear was noted from the adhesive of the mepilex. The clinical record lacked documentation of an assessment of the skin under the mepilexes or the implementation of a treatment order for the skin tear on 2/13/24. During an interview, the Director of Nursing indicated that the mepilexes were believed to be in place for protection due to the resident's fragile skin, and their protocol would be to remove the mepilex unless there was an order not to. The removal of the mepilex resulted in a skin tear due to the adhesive, and there should have been an order implemented for the skin tear, which was not done. The facility's Skin Management Program policy, provided by the Executive Director, emphasized ensuring each resident receives care consistent with professional standards of practice, which was not followed in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Madison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waters Of Clifty Falls, The | 0.5 mi | ★★★★★ | 9 | 0 |
| River Terrace Health Campus | 2 mi | ★★★★★ | 8 | 0 |
| Thornton Terrace Health Campus | 5.2 mi | ★★★★★ | 0 | 0 |
| Aperion Care Hanover | 5.7 mi | ★★★★★ | 24 | 0 |
| Bedford Springs Health And Rehabilitation | 13.2 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.