Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hickory Creek At Sunset during CMS and state inspections, most recent first.
A resident who was cognitively intact was started on mirtazapine, an antidepressant/psychotropic, for weight loss and decreased appetite, but the record lacked documentation that the resident and/or representative were informed of the benefits, risks, alternatives, and black box warning before the medication was initiated. An event report noted the representative was notified of the order, and a later IDT note stated consent was obtained, but neither documented the required pre-initiation disclosure. The ED stated informed consent was normally reviewed during care plan meetings and was not aware it had to be obtained before starting or increasing a psychotropic medication.
Conflicting POST instructions left a resident’s code status unclear. The resident, who had dementia with anxiety and major depressive disorder, said she did not want CPR and felt the admission explanation was inadequate. Staff interviews showed the CNA was unaware of the code status, the LPN said it should be in the chart and POST manual, but the POST form contained contradictory directions and was missing from the code status manual; the DON said the form was confusing and was unsure who reviewed it with the resident.
A resident’s admission MDS was coded as having ID/DD with no organic physical condition, even though the diagnosis list did not document an ID/DD diagnosis. The MDS Coordinator later stated the assessment was coded in error and that the resident did not have an ID/DD. The facility used the CMS RAI manual for MDS coding, which directs staff to code ID/DD status only when present and to use code Z when no ID/DD condition exists.
The facility failed to complete accurate skin assessments and obtain timely treatment orders for two residents. One resident had an abdominal wound with a dated dressing, a bruise on the thigh, and delayed physician notification and treatment documentation after re-admission. Another resident had a healing bruise on the knee after a fall, but multiple weekly skin assessments did not identify or document the skin change, despite staff expectations for head-to-toe skin checks and reporting new skin findings.
A resident with Parkinson's disease, Lewy body neurocognitive disorder, severe cognitive impairment, repeated falls, and marked weakness was moved from a Broda chair back to a manual wheelchair after a decline in condition and hospitalization. The record did not show that OT or nursing documented the resident was safe to be pushed in the wheelchair without foot pedals before transport. While a CNA was pushing the resident, he put his feet down, fell out of the wheelchair, and hit his forehead, with the fall attributed to bilateral LE weakness.
An opened, undated Aspart 100 unit insulin pen prescribed for a resident was found in the North Hall med cart. An LPN stated the pen had been opened the prior evening and acknowledged that insulin pens should be dated when opened. The DON later provided the facility policy requiring opened medications to be dated.
A resident with severe cognitive impairment, Parkinson’s disease, and a feeding tube had a POST form updated to reflect DNR, comfort measures, and long-term artificial nutrition, but the physician’s orders in the chart were not updated to match those selections. The DON stated she was not sure why the orders were not changed, and the facility policy required POST decisions to be added to the resident’s orders.
A resident with a history of falls was injured when her wheelchair, lacking foot pedals, was pushed over a floor dip by a bus driver, causing her to fall and sustain a nasal fracture. Staff interviews revealed uncertainty about foot pedal requirements, and the facility lacked a policy on their use.
A Nursing Assistant in Training (NAIT) failed to follow proper handwashing procedures during a meal service, washing hands for less than 20 seconds and not using a paper towel to turn off the faucet before serving trays to residents. The Director of Nursing confirmed that the NAIT had been trained on the correct technique, which is outlined in the facility's hand hygiene policy.
A resident with quadriplegia and dysphasia was not served a meal tray during lunch, despite requesting a hamburger substitute in advance. The meal was delayed as the kitchen staff had to procure the hamburger externally, causing the resident distress. Discrepancies were noted in whether the resident was offered an alternative meal while waiting.
The facility failed to properly label and dispose of medications, including undated and expired eyedrops and solutions, as observed during a survey. Medications for residents with conditions like diabetes and glaucoma were not managed according to policy, leading to potential risks. The facility's policies on medication storage and expiration were not followed, resulting in these deficiencies.
A resident with PTSD and anxiety experienced psychosocial distress due to the facility's failure to provide appropriate services. The resident was left unattended in the shower room multiple times, exacerbating his anxiety and feelings of abandonment. Despite having a PTSD diagnosis, the facility did not conduct a trauma assessment or develop a trauma-informed care plan, leading to the deficiency.
A resident was left without transportation after a hospital appointment due to the facility's failure to coordinate and communicate transportation arrangements. Despite being assured that transportation was arranged, the resident was left outside the hospital and unable to contact the facility for assistance. An off-duty employee eventually brought the resident back to the facility.
A resident with multiple health conditions, including paraplegia and gastro-esophageal reflux disease, reported that the facility failed to honor his dietary dislikes and preferences, such as avoiding gassy, spicy, and greasy foods. Despite communicating these needs to the dietitian and staff, the resident continued to receive inappropriate meals, and no care plan was documented to address his dietary preferences. The Administrator acknowledged the issue but did not implement alternative communication methods or create a food preference list.
Failure to Document Informed Consent Before Starting Mirtazapine
Penalty
Summary
The facility failed to inform a resident and/or the resident’s representative of the benefits, risks, alternatives, and black box warning for mirtazapine before starting the psychotropic medication for Resident 3. The resident’s quarterly MDS dated 10/22/25 indicated the resident was cognitively intact and had received an antidepressant during the look-back period. A physician’s order dated 9/11/25 directed mirtazapine 15 mg by mouth at bedtime for weight loss, but the medical record did not contain documentation of an IDT Psychotropic New/Increase Order Observation or other documentation showing the resident was notified of the required information before the medication was initiated. The record also included an event report dated 9/10/25 stating the resident’s representative was notified of the order for mirtazapine for depression and decreased appetite, but it did not document that the resident and/or representative were informed of the benefits, risks, alternatives, and black box warning associated with the medication. A later NAR IDT note dated 9/11/25 stated consent was obtained and that the resident and a friend were happy with the initiation of Remeron, but it still lacked documentation that the required information had been provided prior to initiation. During interview, the ED stated informed consent was normally reviewed during care plan meetings and was not aware consent had to be obtained prior to initiating or increasing a psychotropic medication. The DON provided the facility’s Psychotropic Management policy, which stated the IDT Psychotropic New/Increase Order observation in Matrix should be used for initiation or increases of psychotropic medications.
Conflicting POST Form and Unclear Code Status
Penalty
Summary
The facility failed to ensure that Resident 17’s code status was clear, concise, and consistent with the resident’s wishes. The resident’s record showed diagnoses including dementia with anxiety and major depressive disorder. A POST form dated in the record indicated the resident wanted CPR attempted if she had no pulse and was not breathing, but also indicated allow natural death if she had a pulse and was not breathing. The admission MDS showed moderate cognitive deficit and mild depression, and the care plan noted emotional abuse trauma related to being abandoned by her husband, with risk for feeling unsafe, untrusting, and distressed. During interview, the resident stated she did not wish to have CPR performed and said the situation had not been explained well enough at admission; she felt so rattled that she would have likely signed anything placed in front of her. Staff interviews showed CNA 8 was not aware of the resident’s code status, LPN 9 said it should be in the electronic record and POST manual, and the resident’s POST form contained contradictory instructions. Observation of the code status manual showed it lacked the resident’s POST form. The Unit Manager stated she had noticed the conflicting POST information and believed someone had gone back to the resident for clarification, but she could not locate the form in the manual. The DON stated the admission was unusual and she was unsure who reviewed the POST information with the resident; she also acknowledged the POST form was confusing to understand.
Incorrect MDS Coding for ID/DD Status
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident. The resident’s admission MDS, dated 7/21/25, coded the resident as having an intellectual disability or developmental disability with no organic physical condition, but the resident’s diagnosis list did not document any ID or DD diagnosis. During interview, the MDS Coordinator stated the assessment had been coded in error and that the resident did not have an ID or DD. The facility used the CMS RAI manual as its policy for MDS coding, and the cited manual instructions state that A1550 should be coded only for conditions related to ID/DD status that were present before age [AGE], and code Z should be used if no ID/DD condition is present.
Incomplete Skin Assessments and Delayed Wound Treatment
Penalty
Summary
The facility failed to complete accurate skin assessments and obtain treatment orders for two residents with identified skin issues. For one resident, staff observed a bandage on the lower right abdominal fold that was dated several days earlier, and the resident stated it had been applied during a recent hospital stay for an open wound that would not heal. The resident also had a large purple bruise on the right upper thigh, which the resident said occurred in the hospital. The record showed the resident was re-admitted with diagnoses including COPD and type 2 diabetes, had a care plan for skin breakdown risk and bruising risk, and had an admission skin assessment documenting an abrasion to the lower right abdomen. Staff interviews indicated the wound nurse had not changed the dressing, the physician had not been notified on re-admission about the abdominal wound, and treatment orders were not obtained until later. The documentation for this resident also showed inconsistent wound measurements. A physician order later directed cleansing the abrasion and applying mupirocin ointment with a dry dressing. However, wound documentation recorded the abdominal wound as 12 cm by 12 cm on one date, while later documentation recorded it as 1 cm by 1 cm. The DON stated the earlier measurements were incorrect. The facility policy provided by the DON stated that alterations in skin integrity are to be reported to the MD/NP and documented on the admission observation for new admitted and re-admitted residents. For the second resident, staff failed to identify and document a bruise to the right knee on weekly skin assessments after a fall at the facility. The resident had diagnoses including rhabdomyolysis, COPD, and hypertension, and had care plans identifying risk for skin breakdown and the need for weekly skin checks and documentation of abnormal findings. The resident reported a recent fall and showed a healing bruise covering the right kneecap with yellow, green, and purple discoloration and a scab, with tenderness to touch. Fall documentation stated the resident fell onto his buttocks and had no injuries, and multiple weekly skin assessments documented no skin concerns and did not identify the knee bruise. Staff interviews indicated weekly skin assessments should be head-to-toe, new skin imperfections should be documented, and a skin event should be opened when a new skin issue is found.
Unsafe Wheelchair Transport Led to Resident Fall
Penalty
Summary
The facility failed to ensure a resident was safely transported in a wheelchair. The resident had Parkinson's disease, neurocognitive disorder with Lewy bodies, repeated falls, severe cognitive impairment, generalized weakness, and required extensive assistance with activities of daily living. The record showed the resident had used a manual wheelchair with a pommel cushion, anti-rollbacks, and a foot board, and had a history of declining condition, lethargy, swelling, and total dependence after returning from the hospital with metabolic encephalopathy and a g-tube. After the resident returned from the hospital, therapy notes and nursing documentation described a change in function and positioning needs. The resident had been placed in a Broda chair, was later moved back to a manual wheelchair, and the record did not document that OT or nursing had determined the resident was safe to be placed back in the manual wheelchair or safe to be pushed in it without foot pedals despite increased muscle weakness and change in condition. The resident was noted to be more alert on the day of the fall, but the chart lacked documentation that his ability to be safely pushed in the wheelchair had been reassessed before transport. During transport, the CNA pushed the resident in the wheelchair, the resident put his feet down, and he fell out of the wheelchair, striking his forehead and sustaining abrasions. The progress note and IDT note documented the fall and identified weakness to both lower extremities as the root cause. The record also showed that the intervention of foot pedals was added after the fall, and interviews indicated staff had not obtained or used foot pedals on their own in response to the resident's change in condition before the incident.
Undated Open Insulin Pen in Medication Cart
Penalty
Summary
The facility failed to provide the open date for an insulin pen stored in one of two medication administration carts. During observation of the North Hall medication administration cart on 11/20/25 at 9:55 a.m., surveyors found an opened, undated Aspart 100 unit insulin pen prescribed for Resident 5. At 10:00 a.m., an LPN stated the insulin pen had been opened on 11/19/25 in the evening and acknowledged that insulin pens should be dated when opened. Later, the DON provided the facility policy titled, Storage and Expiration Dating of Medications and Biologicals, dated 06/30/25, which stated that opened medications should have the date opened recorded on the primary medication container when the medication has a shortened expiration date once opened, and that an opened multidose vial of injectable medication should be dated and discarded within 28 days unless the manufacturer specifies אחרת.
Physician Orders Not Updated to Match POST Form
Penalty
Summary
The facility failed to ensure a resident’s medical record was accurate when the physician’s orders were not updated to match the resident’s selections on the POST form. Resident 1 had diagnoses including nontraumatic intracranial hemorrhage and Parkinson’s disease, and an admission MDS dated 10/9/25 indicated severe cognitive impairment and a feeding tube. The resident’s record showed physician’s orders dated 2/5/24 for CPR, full medical interventions, antibiotics consistent with treatment goals, and no artificial nutrition. After the resident returned from the hospital stay, an updated POST form was signed on 10/10/25. That form indicated do not attempt CPR, comfort measures/allow natural death, use antibiotics consistent with treatment goals, and long-term artificial nutrition. The record lacked documentation that the physician’s orders were updated to reflect the new POST selections. During interview, the DON stated she was not sure why the physician’s orders were not updated in October when the resident’s POST preferences changed, and the facility policy stated that physician’s orders indicating POST decisions are to be added to the resident’s orders.
Resident Falls Due to Lack of Wheelchair Foot Pedals
Penalty
Summary
The facility failed to ensure the safe transportation of a resident in a wheelchair, resulting in a fall and nasal fracture. Resident B, who was admitted with a right shoulder and hip fracture, was being transported by the facility's bus driver to an appointment. During the transport, the bus driver pushed the resident's wheelchair over a dip in the floor, causing the resident's foot to catch on the floor. The resident was not using foot pedals at the time, which led to her falling face-first out of the wheelchair, resulting in a sprained foot, a fractured nose, and a black eye. Interviews with staff revealed that the resident's sneakers caught on the floor, contributing to the fall. The bus driver attempted to prevent the fall by grabbing the resident's shoulders but was unsuccessful. It was noted that the resident's wheelchair did not have foot pedals in place during the incident, and there was uncertainty among staff about whether foot pedals were required. The facility did not have a policy regarding the use of foot pedals at the time of the incident. The resident's medical records indicated she was cognitively intact and dependent on staff for mobility. The fall was witnessed, and the resident experienced pain and bruising. The facility's fall management policy required comprehensive, resident-centered fall prevention plans, but the lack of foot pedals during transport was identified as a contributing factor to the fall.
Improper Handwashing During Meal Service
Penalty
Summary
The facility failed to ensure proper handwashing procedures during a lunch meal service, as observed on 9/5/24. A Nursing Assistant in Training (NAIT) was seen washing hands for less than the required 20 seconds and turning off the water faucet without using a paper towel as a barrier. This improper hand hygiene was followed by the NAIT serving meal trays to multiple residents in the dining room. During an interview on 9/10/24, the Director of Nursing (DON) confirmed that all staff should be aware of the proper handwashing technique, and the NAIT had been trained on this procedure. The facility's hand hygiene policy, revised in 7/2022, clearly outlines the steps for proper handwashing, including rubbing hands for at least 20 seconds and using a paper towel to turn off the faucet.
Failure to Ensure Resident Dignity During Meal Service
Penalty
Summary
The facility failed to ensure the dignity of a resident, identified as Resident B, during a meal service. During a lunch observation, Resident B, who required substantial assistance with eating due to quadriplegia and dysphasia, was not served a meal tray while another resident at the same table was assisted with their meal. Resident B had requested a hamburger as a substitute meal prior to being brought into the dining room, but the meal was delayed because the kitchen staff had to procure the hamburger from outside the facility. This resulted in Resident B having to wait for her meal, which she expressed was upsetting. Interviews conducted revealed discrepancies in the accounts of whether Resident B was offered an alternative meal while waiting. The Certified Food Manager indicated that Resident B was offered something else, which she declined, while the Executive Director mentioned that cottage cheese was offered. However, Resident B did not recall being offered any alternative and stated she would have accepted cottage cheese if it had been offered. The facility's policy on resident rights, which includes the right to be treated with dignity and to decide on meals, was provided by the Executive Director.
Medication Labeling and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and disposal of medications and biologicals, as observed during a survey. An opened and undated bottle of Brimonidine eyedrops was found in the West/North medication cart, intended for a resident with type two diabetes. The facility's policy was not to use eyedrops after 30 days of opening, but the Director of Nursing (DON) indicated that the expiration date depended on the medication. Additionally, an opened bottle of Latanoprost eyedrops with an expired use-by date was found, and it was unclear if it had been administered past its expiration. This medication was for a resident diagnosed with glaucoma. Another deficiency was noted with an opened and undated bottle of Refresh Relieva eyedrops, which lacked a current physician's order. The historical order for these drops had been discontinued, and the nurse confirmed they should have been discarded. Furthermore, an opened and undated multidose vial of Lidocaine HCL 1% solution was found, which was used to reconstitute a resident's Ceftriaxone injection. The facility's policy required such vials to be dated when opened. The survey also found a container with five vials of Tuberculin solution, one of which was opened and undated, in the back hall medication room. The facility's policy required opened vials to be dated and discarded within 30 days. The DON provided several policies and guidelines, including those for storage and expiration dating of medications, which were not adhered to, leading to these deficiencies.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide appropriate services to a resident with a history of post-traumatic stress disorder (PTSD) and anxiety, resulting in psychosocial distress. The resident, who was alert and meticulous in record-keeping, reported severe abandonment anxiety stemming from a traumatic incident involving his wife. Despite being aware of his mental health issues, the facility did not offer him psychiatric services, and he relied on external psychiatric care. The resident experienced multiple instances of being left unattended in the shower room, which exacerbated his anxiety and feelings of abandonment. On several occasions, the resident was left in the shower room without assistance, despite having a call light that was supposed to alert staff. The call light cord was initially extended with a string, which was later removed due to safety concerns, and replaced with a bell that was ineffective in summoning help. The resident reported being left for extended periods, including one instance where he was left for about 1.5 hours, causing him to become upset and fearful. He also experienced a lack of communication and support during a hospital visit for an MRI, where he was left waiting for transportation back to the facility, further contributing to his distress. The facility's documentation lacked evidence of a trauma assessment or a care plan for trauma-based care, despite the resident's PTSD diagnosis. The care plans in place addressed anxiety and depression but did not incorporate trauma-informed care practices. The facility's policy on trauma-informed care required referrals to behavioral health services and the development of a care plan, which was not evident in the resident's medical record. This oversight in providing trauma-informed care and ensuring the resident's psychosocial well-being led to the deficiency noted in the report.
Failure to Arrange Transportation for Resident
Penalty
Summary
The facility failed to assist Resident G in obtaining transportation from a hospital appointment, resulting in the resident being left without a way to return to the facility. On 5/28/24, Resident G was sent to the hospital for an MRI and was assured by a nurse that his transportation was arranged. However, after completing the MRI, Resident G was left outside the hospital as the transportation van did not arrive. Despite his attempts to contact the facility for assistance, no one answered his calls for about 30 minutes. An off-duty employee of the facility, who happened to see Resident G outside the hospital, eventually brought him back to the facility. Interviews with facility employees revealed a lack of communication and coordination regarding Resident G's transportation. Employee 3, who encountered Resident G at the hospital, observed him making multiple unsuccessful calls to the facility. Upon contacting the facility, Employee 3 was informed by a supervisor that no one was aware of the transportation arrangements. Additionally, Employee 5 confirmed that there was confusion among staff about who was responsible for Resident G's pickup, and no one had the transportation company's contact information. Resident G's medical record indicates he has multiple diagnoses, including paraplegia, diabetes, generalized anxiety disorder, and major depressive disorder, which may have exacerbated his distress during the incident.
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to honor a resident's dietary dislikes and food preferences, specifically for Resident G, who was one of the three residents reviewed for food preferences. Resident G, who suffers from paraplegia, gastro-esophageal reflux disease, diabetes, generalized anxiety disorder, and major depressive disorder, reported that he cannot tolerate gassy, spicy, or greasy foods due to digestive issues related to his paralysis. Despite having communicated these preferences to the dietitian upon admission and repeatedly informing the staff, Resident G continued to receive meals that did not align with his dietary needs, such as sausage and eggs, and sausage pizza, which he could not tolerate. The facility's failure was further highlighted by the absence of a documented care plan addressing Resident G's dietary preferences in his medical record. The Administrator acknowledged that the diet ticket did not reflect the resident's dislikes, attributing it to the resident's alleged frequent changes of mind. However, no food preference list was created for Resident G, and the Administrator admitted to not exploring alternative communication methods for the resident to express his preferences. This deficiency was noted in relation to a complaint, and the facility's policy on Residents Rights emphasized the right to reasonable accommodation of needs and preferences, which was not upheld 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 Greencastle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Asbury Towers Health Care Center | 0.7 mi | ★★★★★ | 10 | 0 |
| Waters Of Greencastle, The | 1.3 mi | ★★★★★ | 12 | 0 |
| Mill Pond Health Campus | 1.4 mi | ★★★★★ | 10 | 0 |
| Aperion Care Summerfield | 9.2 mi | ★★★★★ | 0 | 0 |
| Cloverleaf Of Knightsville | 14 mi | ★★★★★ | 6 | 0 |
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