Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Manor during CMS and state inspections, most recent first.
Failure to Provide Required Medicare Non-Coverage Notices: A resident was discharged from skilled therapy services without receiving the required SNF ABN or NOMNC in writing at least 2 calendar days before coverage ended. The IDT discussed the discharge, but the SSD and MDS Coordinator were aware of the upcoming end of skilled services and the notices were not issued or signed by the resident or representative.
A facility failed to maintain a safe, clean, and homelike environment. Surveyors observed foggy dining room windows, an unattached toilet seat lid, scratched and scuffed doors, a discolored toilet seat, a bathroom door with a patched hole, an unfinished ceiling patch, and moisture damage on a vent register. A resident reported telling staff more than a month earlier that the toilet lid was broken and moved when used, and the maintenance log showed one repair request that remained incomplete with no documentation for the other concerns.
Failure to Assess Bed and Chair Alarms as Restraints: A resident with dementia, repeated falls, disorientation, orthostatic hypotension, and difficulty walking had bed and chair alarms used for fall prevention, but the record did not show assessment of whether the devices were restraints, a medical symptom supporting their use, or least restrictive use. The physician order and assistive device assessment referenced impaired cognition, high fall risk, and family request, while observations showed the resident seated with a chair alarm sensor under the buttocks and unable to remove it; the resident said the alarm sometimes made a loud noise that scared him/her.
Failure to complete required pre-employment screening: the facility did not verify several new hires against the CNA Registry and EDL before they began work. Personnel records for 6 of 10 sampled employees lacked the required checks, despite facility policy requiring CNA Registry review for all new hires and background screening before work. The BOM said he/she misunderstood the EDL timing and was unaware the CNA Registry had to be checked for every employee, while the Administrator and RNC acknowledged the expected pre-hire verification process.
A resident was admitted to hospice after a decline and hospital stay, but the facility did not complete a significant change MDS within the required timeframe. The MDS Coordinator acknowledged that a significant change assessment was needed when a resident goes on hospice, but was unsure of the timing requirement.
MDS Not Accurately Coded for Fall With Major Injury: A resident with respiratory failure, COPD, anxiety, bipolar disorder, depression, substance abuse, PTSD, opioid dependence, and falls had a fall after tripping over oxygen tubing and an oxygen tank, resulting in a fractured hand and hospital evaluation. The resident’s significant change MDS did not reflect a fall with major injury, even though the resident, MDS Coordinator, Corporate MDS Coordinator, RNC, and Administrator all stated that such an injury should have been documented.
Failure to develop person-centered care plans for medications, wounds, and catheter care: Two residents had care plans that did not address key needs. One resident with stroke, depression, anxiety, neuropathic bladder, a pressure ulcer, and multiple meds including an antipsychotic, anxiolytics, an anticoagulant, pain meds, an antidepressant, and a hypnotic had no person-centered interventions for those orders. Another resident with coccyx and left buttock pressure ulcers and a urinary catheter also lacked individualized care plan interventions for those issues.
A resident with multiple psychiatric and medical diagnoses, including PTSD, had a care plan that did not address PTSD triggers or interventions. The resident reported that closed-in spaces and loud sudden noises triggered PTSD and kept the door from closing fully, and staff interviews confirmed that PTSD should have been reflected on the individualized care plan with triggers identified and interventions in place.
An LPN failed to follow policy and accepted nursing practice during transdermal pain patch administration for a resident with chronic pain. The LPN removed the old patch, placed it on a bedside table, applied the new patch to the same site, then handled the used patch with bare hands while transporting the resident in a wheelchair and disposed of it in a sharps container.
A resident with COPD, respiratory failure, PTSD, bipolar disorder, depression, substance abuse, and tobacco use had repeated unsafe smoking incidents, including smoking in the room, smoking with O2 in use, and leaving the facility to smoke without staff supervision. The resident’s last smoking assessment showed supervision was required, but no quarterly reassessments were completed after that, and the care plan did not reflect updated interventions after repeated non-compliance and fire-safety incidents.
A resident with PTSD, anxiety, bipolar disorder, and depression had prazosin ordered for chronic PTSD, but the care plan and trauma-informed assessment did not identify any PTSD triggers or interventions. The resident reported that closed-in spaces and loud sudden noises were triggers and kept the door from closing with a hanger, which was also observed by surveyors. The SSD was unsure who completed the trauma assessment, and the Administrator and RNC stated that a resident with PTSD should have individual triggers and interventions in place.
A resident with bipolar disorder, anxiety, depression, PTSD, substance abuse, opioid dependence, and tobacco use had repeated aggressive, disruptive, and unsafe smoking-related behaviors, including smoking in the room despite O2 concerns, arguing with staff, refusing care, attempting to light a cigarette near an O2 tank, and encouraging another resident to pull an exit door alarm. Although staff repeatedly documented the behaviors and gave education, the care plan did not include individualized interventions for the resident’s verbal aggression or disruptive conduct, and staff, including the DON and Administrator, were observed failing to redirect or de-escalate the behavior.
Failure to Follow EBP and Hand Hygiene During Care: The DON provided wound care to two residents with wounds without EBP signage or gown use, and for one resident did not perform hand hygiene or change gloves during the procedure. An LPN also failed to perform hand hygiene before and after transdermal pain patch administration, did not change gloves, placed the used patch on a bedside table, handled it with bare hands, and carried it into the hallway before disposal.
Ineffective pest control allowed a fly infestation in the dining and meal service areas. Flies were observed crawling on residents, their food, utensils, dessert bowls, hands, and exposed food trays during meals, and staff and residents described the problem as horrible, terrible, and a major pest issue. The Administrator acknowledged awareness of the fly concern, and the pest control invoice showed services did not target flies.
A resident with multiple chronic conditions and pressure ulcers, who was dependent on staff for bathing, did not receive scheduled showers as required. Over a three-week period, the resident received only two showers, with no documentation of refusals or reasons for missed care. Staff interviews confirmed showers should occur twice weekly and refusals should be documented, but this was not done, resulting in the resident having greasy hair and an unkempt appearance.
The facility did not follow its policies for completing Criminal Background Checks (CBC) and Nurses Aide (NA) Registry verifications for new hires. CBCs were not completed for four out of ten sampled staff, and NA Registry checks were not done for seven out of ten sampled staff. The Administrator was unaware that all staff required NA Registry checks, leading to non-compliance with established procedures.
A facility failed to implement an accurate baseline care plan for a resident within 48 hours of admission, omitting necessary interventions for a Stage II sacral wound. The resident had multiple diagnoses, including atrial fibrillation and chronic kidney disease, and required daily wound care, which was not addressed in the care plan. Interviews confirmed the care plan should have included the resident's immediate needs.
The facility failed to implement comprehensive care plans with specific interventions for four residents, leading to deficiencies in addressing their individual needs. One resident experienced significant weight loss without tailored strategies in the care plan. Another resident's care plan lacked specific interventions for wound care, while a third resident's plan did not address pain management and anticoagulant use. A fourth resident also experienced significant weight loss without individualized strategies in the care plan.
The facility failed to follow physician's orders for oxygen administration for two residents and wound care for another. One resident received oxygen at 8 liters instead of the prescribed 6 liters, while another received 4 liters instead of 6. Additionally, an LPN improperly applied Santyl to a dressing rather than directly to a resident's wound. Interviews confirmed staff were expected to adhere to physician's orders.
The facility failed to obtain physician orders for RD-recommended supplements and did not ensure nutritional assessments for residents with significant weight loss. Four residents experienced severe weight loss without receiving the recommended supplements. Communication issues and procedural lapses were evident, as the RD's recommendations were not promptly addressed, and assessments were not conducted as per policy.
The facility failed to reconcile narcotics at each shift change for two medication carts, as required by their policy. Reviews of narcotic count logs from October 2024 to January 2025 showed numerous missed reconciliations. Interviews with staff confirmed the expectation for reconciliation by off-going and on-coming staff, but logs indicated consistent failures to adhere to this policy.
The facility failed to monitor and adjust the psychotropic medication regimen for residents, resulting in PRN orders exceeding 14 days without clinical rationale and lack of gradual dose reductions. The consultant pharmacist's recommendations were not addressed with the physician, leading to unaddressed medication irregularities. Interviews revealed a system failure in ensuring timely review and compliance with pharmacy recommendations.
The facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for three residents, leading to deficiencies in infection prevention and control. A resident did not have EBP signage, and an LPN did not wear an isolation gown during wound care. Another resident's RN failed to change gloves and perform hand hygiene after handling a bloody wound. For a third resident, an RN left the room without removing PPE or performing hand hygiene. The DON was unaware of missing EBP signage and acknowledged the need for proper PPE use.
The facility failed to develop and implement comprehensive care plans for two residents within the required timeframe due to a transition to electronic medical records (EMR). Despite having significant medical needs and behaviors such as delusions and wandering, the care plans for these residents were not completed as required. Interviews with staff, including the DON and MDS coordinator, confirmed that the transition to EMR was the cause of the delay.
The facility failed to follow physician's orders for multiple residents, resulting in missed treatments and inadequate documentation. A resident did not receive prescribed wound care, while another had missed medication doses and improper documentation of oxygen equipment maintenance. Observations and interviews confirmed these deficiencies, highlighting systemic issues in care delivery.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and a Notice of Medicare Non-Coverage (NOMNC) in writing at least two calendar days before the end of skilled services for one resident. Resident #31 was discharged from skilled services on 01/05/26 but remained in the facility, and the resident's skilled services ended on 01/03/26. The NOMNC letter was not issued and signed, and the SNF ABN letter was not issued and signed, so the resident and/or resident representative did not receive the required two-calendar-day notice before skilled services ended. The facility policy stated that a Medicare beneficiary is to be informed in advance and in writing when Medicare payment denial or a change in coverage is likely, and that a NOMNC is to be issued at least two calendar days before Medicare-covered services end. During interview, the Director of Therapy stated the discharge was discussed in an IDT meeting and that the SSD and MDS Coordinator were made aware of the upcoming discharge, but the SNF ABN and NOMNC were not given to the resident or resident representative to be signed. The SSD and Administrator both stated the notices should be provided two to three days, or 48 to 72 hours, before discharge from therapy services.
Unsafe and Poorly Maintained Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment. Observations showed three dining room windows with foggy condensation build-up inside the panes that obstructed or prevented visibility. In room [ROOM NUMBER], a toilet seat lid was unattached and not secured to the toilet inside the bathroom. On the 100 Hall, several deep horizontal scratches and scuffed marks were observed across the width of the doors in Rooms 101, 104, 105, 112, and the beauty salon, and a toilet seat in room [ROOM NUMBER] had multiple discolored areas and peeled paint. The resident in room [ROOM NUMBER] stated he/she had told staff more than a month earlier that the toilet lid was broken and needed repair, and that the lid moved and slid when he/she sat down to use the bathroom. In room [ROOM NUMBER] Hall, a baseball-size hole in the bathroom door was filled with a discolored putty-like substance with an uneven, unsanded surface, a baseball-size hole on the ceiling was patched with drywall-like tape and left unfinished, and the bathroom ceiling ventilation register showed moisture damage and discoloration. The Maintenance Log binder showed a repair request for the toilet seat in room [ROOM NUMBER] dated 04/08/26 that was not completed, and there was no documentation that the other areas of concern had been addressed. The Housekeeper said environmental concerns were reported directly to the maintenance supervisor or written on the maintenance log, and the Maintenance Supervisor said he checked the log each morning but had been away recently and was unsure of some of the areas needing attention. The Administrator said staff were expected to document needed repairs or environmental concerns on the maintenance log for timely follow-up.
Failure to Assess Bed and Chair Alarms as Restraints
Penalty
Summary
The facility failed to properly assess the use of a bed alarm and chair alarm for one resident to determine whether the devices were being used as restraints, failed to identify a medical symptom supporting their use, and failed to document the least restrictive use of the alarms. The resident had diagnoses including dementia, weakness, repeated falls, disorientation, orthostatic hypotension, cellulitis of the lower limb, and difficulty walking. The record showed no documentation of restraint assessment or consent for the alarms, no documentation of a medical symptom to support their use, and no documentation of least restrictive use. The physician order for the bed/chair alarm cited impaired cognition, high fall risk, and family request, but did not address a medical symptom for use of the alarms. The resident’s assessment for assistive device stated that the family provided the alarm due to falls and that the resident was a fall risk due to a medical condition, but it did not assess whether the chair and bed alarms were utilized as restraints, did not provide a medical symptom for their use, and did not address least restrictive use. The quarterly MDS showed severely impaired cognition, wandering, partial to moderate assistance with toileting, substantial to maximal assistance with sit-to-stand and transfers, wheelchair use, and that bed and chair alarms were not used. The care plan included chair and bed alarms for fall risk related to gait and balance problems, but did not address fall-related interventions, restraint status, medical symptom, or least restrictive use. Observations showed the resident seated in a wheelchair and recliner with a chair alarm sensor under the buttocks and unable to remove it, and the resident stated the chair alarm sometimes made a loud noise that scared him/her and that he/she would rather it not do that.
Failure to Complete Required Pre-Employment Screening
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was deficient because the facility did not ensure required pre-employment screenings were completed for abuse, neglect, or misappropriation of property. Review of personnel files showed no documented verification of the Nurse Aide Registry for Employees #2 and #3 before their hire dates, and no documented verification of the Employee Disqualification List (EDL) for Employees #5, #6, #7, and #9 before their hire dates. The facility census was 39, and the deficiency affected 6 of 10 sampled employees. The facility’s policy required checking the CNA Registry for all new hires and stated that all employees before starting work would have a State Police Background Check completed. During interview, the Business Office Manager said he/she had only been working at the facility for about three months and thought the EDL should be completed quarterly, and was not aware the Nurse Aide Registry was required to be checked on every employee. The Administrator stated she was aware there was some concern with the background checks and had informed the BOM that the facility would be completing the employee verification packet from that day forward. The Regional Nurse Consultant stated she would expect staff to complete everything on pre-hire before staff would be able to work and to check the EDL quarterly.
Failure to Complete Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a significant change MDS within 14 days of a resident’s admission to hospice services. Resident #27 was admitted to hospice on 04/15/26, but the record showed no significant change MDS dated on or after that date. The facility policy identified significant change status assessments as federally mandated OBRA assessments, and the resident assessment coordinator was responsible for ensuring timely and appropriate assessments. During interview, the Administrator stated the resident had been in the hospital, had declined, and the family requested hospice services. The MDS Coordinator stated that a significant change MDS would be needed when a resident went on hospice, but was unsure of the required timeframe and believed it might be 30 days.
MDS Not Accurately Coded for Fall With Major Injury
Penalty
Summary
The facility failed to accurately code the MDS for one resident out of 12 sampled residents. Resident #7 was admitted with diagnoses including respiratory failure, COPD, anxiety, bipolar disorder, depression, psychoactive substance abuse, tobacco use, PTSD, opioid dependence, and falls. The resident had a fall on 12/28/25 and was sent to the hospital for evaluation the same day, then returned to the facility on 12/29/25 with a closed, non-displaced fracture of the fifth metacarpal. The resident’s care plan was revised on 12/29/25 and identified risk for fall/injury related to ambulating with oxygen. The resident’s significant change MDS assessment dated 01/23/25 indicated no fall with a major injury, even though the record and interviews showed the resident had fallen and sustained a fractured hand. During interview, the resident stated he/she had fallen a couple of times after tripping over oxygen tubing and an oxygen tank, resulting in a fractured hand. The MDS Coordinator, Corporate MDS Coordinator, Regional Nurse Consultant, and Administrator each stated that a resident with a fall with major injury should have been documented on the MDS assessment.
Failure to Develop Person-Centered Care Plans for Medications, Wounds, and Catheter Care
Penalty
Summary
The facility failed to develop and implement care plans with specific, person-centered interventions for two sampled residents. For one resident, the medical record showed diagnoses including stroke affecting the right side, major depressive disorder, generalized anxiety, neuropathic bladder, spinal stenosis, stage 3 pressure ulcer, and paroxysmal atrial fibrillation. The resident also had orders for brexpiprazole, diazepam, hydroxyzine, Eliquis, hydrocodone-acetaminophen, tramadol, trazodone, and zolpidem, but the revised care plan did not address these medications with person-centered interventions. For another resident, the medical record showed a stage 2 pressure ulcer to the coccyx and left buttock and a urinary catheter, with orders for wound care to both pressure areas. The care plan dated 03/20/26 did not address the coccyx and left buttock pressure ulcers or the urinary catheter with person-centered interventions. During interviews, the MDS Coordinator and Administrator stated they would expect blood thinners, antipsychotics, antianxiety medications, antidepressants, urinary catheters, and wounds to be addressed on the care plan with individualized interventions.
Care Plan Not Updated for PTSD Triggers and Interventions
Penalty
Summary
The facility failed to update and revise the care plan with specific interventions tailored to meet the individual needs of one resident, Resident #7, out of 12 sampled residents. The resident was admitted with diagnoses including respiratory failure, COPD, anxiety, bipolar disorder, depression, psychoactive substance abuse, tobacco use, opioid dependence, and falls, and later received a new diagnosis of PTSD dated 12/05/25. The physician order sheet included Prazosin 2 mg, 2 capsules by mouth daily related to chronic PTSD. The resident's care plan, revised 12/29/25, did not address PTSD and did not identify triggers or interventions. The Trauma Informed Consent Assessment dated 04/15/26 also showed no PTSD triggers indicated. During interview, the resident stated that closed-in spaces and loud sudden noises triggered PTSD and that the door should not be completely shut, which was consistent with observations showing a plastic hanger on the doorknob preventing the door from closing on multiple occasions. The MDS Coordinator, Administrator, and Regional Nurse Consultant each stated that a resident's PTSD diagnosis should be reflected on the individualized care plan with triggers identified and interventions in place.
Improper Transdermal Patch Handling and Disposal
Penalty
Summary
The facility failed to ensure nursing staff followed professional standards of practice for medication administration for one resident, who was admitted with a diagnosis of chronic pain. During observation of transdermal pain patch administration, an LPN put on gloves, opened and labeled a new patch, then removed the old patch from the resident's lower back after finding it secured with tape. The LPN placed the medicated side of the used patch directly on the bedside table, applied the new patch to the same lower back location, removed gloves, and then picked up the used patch with bare hands. The LPN carried the used patch in a bare hand while pushing the resident in a wheelchair into the hallway and disposed of the patch in a sharps container on the medication cart. The facility policy titled, Transdermal Drug Delivery System Patch Application, required removal of the old patch, wearing gloves when handling patches, rotating patch application sites, and disposing of patches appropriately. During interviews, the RNC said staff should remove the old patch while wearing gloves and not place it on a bedside table, and the Administrator said staff should rotate patch sites and should not carry used pain patches with bare hands while transporting residents in the hallway. The LPN later stated he/she carried the used patch without gloves into the hallway before disposal.
Unsafe Smoking Supervision and Missed Smoking Assessments
Penalty
Summary
The facility failed to ensure a safe environment during smoking by not providing adequate supervision while smoking and failed to complete smoking assessments at least quarterly for one resident. The resident involved had diagnoses including respiratory failure, COPD, anxiety, bipolar disorder, depression, psychoactive substance abuse, tobacco use, PTSD, opioid dependence, and falls. The resident’s last completed quarterly smoking assessment was dated 08/11/25 and indicated supervision was required during designated smoke times, but no other quarterly smoking assessments were completed after that date. The resident’s record documented repeated smoking-related incidents and unsafe behavior. Notes described smoke odors in the resident’s room, the resident reporting that cigarettes were hidden outside near a trash can, smoke haze in the room, and the resident stating that if denied smoking outside, he/she would smoke in the room and lie about it. Additional entries documented the resident wanting to smoke during secured hours, leaving the facility without staff assist, refusing to surrender a lighter, smoking in the room with oxygen present, and making an open flame while oxygen was in use. The resident also disclosed keeping cigarettes in the room and smoking half cigarettes outside and later in the room. On observation, the resident signed out, received one cigarette from a CMT, walked with an oxygen tank, disconnected the oxygen tubing at the front door, and went to the gazebo, the designated smoking area for independent smokers, where he/she smoked without staff supervision. The resident then returned, reconnected the oxygen tubing, and returned the lighter to the DON. The resident’s care plan identified the resident as a tobacco user who required supervision because he/she was not safe to smoke independently, but it did not address updated interventions after repeated incidents of non-compliance or fire-safety re-education. The Administrator stated the facility was aware of the safety concern, and the DON and SSD had discussed the resident’s smoking and oxygen use.
Failure to Identify PTSD Triggers and Supportive Interventions
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for a resident with a diagnosis of PTSD. The resident had diagnoses of anxiety, bipolar disorder, and depression, and a new PTSD diagnosis dated 12/05/25. The physician order sheet included prazosin 2 mg, 2 capsules by mouth one time a day related to chronic PTSD, but the resident’s care plan revised 12/29/25 did not address PTSD, identify any triggers, or include interventions. The Trauma Informed Consent Assessment dated 04/15/26 also did not indicate any PTSD triggers. During interview, the resident stated that closed-in spaces and loud sudden noises triggered PTSD symptoms and that the door should not be completely shut, using a door hanger to keep it open. Observations on three separate dates showed a plastic hanger on the doorknob preventing the door from closing. The Social Services Director stated they were not sure who completed the trauma assessments, while the Administrator and Regional Nurse Consultant stated that a resident with PTSD should have individual triggers identified and interventions in place.
Failure to Address Ongoing Behavioral and Smoking Safety Issues
Penalty
Summary
The facility failed to ensure sufficient staff competencies and behavioral health interventions for a resident with bipolar disorder, anxiety, depression, PTSD, psychoactive substance abuse, opioid dependence, and tobacco use. The resident had repeated documented behaviors including smoking in the room despite oxygen safety concerns, arguing with staff, refusing education, manipulating staff, repeatedly requesting medications, hiding cigarettes, refusing pulmonary rehabilitation, refusing showers, and attempting to leave the facility outside approved smoking times. The resident also required oxygen at 3 liters per nasal cannula and was documented attempting to light a cigarette near an oxygen tank and smoking near the staff entrance/vending area while refusing to extinguish the cigarette. The resident’s care plan addressed smoking safety, impaired safety awareness, depression, anxiety, and mood monitoring, but did not include individualized interventions for the resident’s ongoing verbally aggressive and disruptive behaviors toward residents and staff. The record also did not show changes to fire safety interventions after repeated re-education documented in the notes. Facility staff repeatedly documented the behaviors and provided education about smoking and oxygen safety, but the resident continued the same behaviors, including attempting to sign out another resident to smoke, encouraging another resident to pull the exit door handle and activate the alarm, and pushing a resident in a wheelchair outside to smoke. During observation, the resident was verbally aggressive toward another resident at the nurse’s station, loudly argued with a CMT about pain medication in front of others, and encouraged another resident to repeatedly pull the exit door handle while demanding residents be taken outside to smoke. The DON, CMT, CNA, and Administrator were present during these events and did not redirect, intervene, or de-escalate the behavior. Interviews with the Administrator, DON, CMT, SSD, RNC, and other staff confirmed the resident’s aggressive and disruptive behavior was considered baseline, that there were no interventions that worked, and that staff were unaware of any activity plan or redirection interventions in place.
Failure to Follow EBP and Hand Hygiene During Wound Care and Patch Administration
Penalty
Summary
The facility failed to follow enhanced barrier precautions for two residents with wounds. Resident #9 had wound care performed by the DON and CNA/CMT I, but there was no EBP signage or PPE available outside the room, and the DON entered the room without a gown, performed hand hygiene, put on gloves, and completed the wound care. Resident #6 also had wound care performed without EBP signage or PPE outside the room, and the DON entered without a gown, performed hand hygiene, and put on gloves before providing care. During Resident #6’s wound care, the DON used wound cleanser-soaked gauze to cleanse the wound on the left shin, did not perform hand hygiene, and did not change gloves during the procedure. The DON then removed gloves, performed hand hygiene, and exited the room. In interviews, the DON stated residents with wounds requiring a dressing needed a gown and gloves before care, and acknowledged not wearing a gown during the wound care for Residents #6 and #9. Other staff interviews showed differing understanding of when EBP applied, including wounds, infections, and open wounds. The facility also failed to perform hand hygiene and change gloves during medication administration for Resident #11. During transdermal pain patch administration, LPN G did not perform hand hygiene before the procedure, put on gloves, removed the old patch, placed it directly on the bedside table, did not perform hand hygiene or change gloves, applied the new patch, removed gloves, and then handled the used patch with bare hands. The used patch was carried into the hallway and disposed of in a sharps container on the medication cart without hand hygiene being performed. The LPN later stated he/she normally performed hand hygiene before and after medication administration and should not have carried the used patch without gloves into the hallway.
Ineffective pest control allowed flies in dining and meal service areas
Penalty
Summary
The facility failed to maintain an effective pest control program to control the fly population in the building. The facility’s policy stated it would maintain an ongoing pest control program to keep the building free of insects and rodents, and a pest control invoice dated 04/23/26 showed services did not target flies and noted an exit door that did not close or seal properly and required weather stripping. The facility census was 39. Observations in the dining room showed flies present during meals and on resident food and personal items. On 04/27/26, flies were seen buzzing around and crawling on residents, their food, dessert bowls, spoons, hands, and exposed food trays on a cart near the kitchen door. On 04/28/26, four flies crawled on a back table while breakfast plates were being served. On 04/29/26, residents were observed eating lunch while flies crawled on their food. Residents and staff described the fly problem as bad, horrible, terrible, and a major pest issue, and the Administrator stated she was aware of the fly concern and would speak with maintenance staff.
Failure to Provide Scheduled Showers and Document Care for Dependent Resident
Penalty
Summary
The facility failed to provide scheduled showers for a resident who was dependent on staff for activities of daily living, including bathing and personal hygiene. The resident, who had multiple diagnoses such as hypertension, peripheral vascular disease, COPD, chronic pain, arthritis, and both Stage Two and Stage Three pressure ulcers, was scheduled to receive showers twice a week according to facility policy and assignment sheets. However, medical record review showed the resident only received two showers over a three-week period, with no documentation of refusals or reasons for missed showers. The resident reported not having a shower in the past ten days and stated that it was common to go without showers for ten to fourteen days, despite wanting showers twice a week. Observation of the resident revealed greasy hair and an unkempt appearance, indicating a lack of personal hygiene care. Interviews with staff, including a CNA, LPN, and the DON, confirmed that residents are scheduled for showers at least twice a week, and that refusals or issues should be documented and reported. However, there was no evidence that refusals were documented or that the lack of showers was addressed, and the DON was unaware of the issue due to the absence of complaints from the resident.
Failure to Complete Background and Registry Checks for New Hires
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the completion of Criminal Background Checks (CBC) and the verification of the Nurses Aide (NA) Registry for new hires. Specifically, the facility did not complete CBCs for four out of ten sampled staff before their hire dates and failed to check the NA Registry for seven out of ten sampled staff. This oversight was identified through interviews and record reviews, revealing that the facility did not maintain documentation of these checks in the personnel files as required by their policies. The facility's policies, dated September 2021 and February 2022, clearly state that background checks and NA Registry verifications must be completed before employment and maintained in personnel files. However, the Administrator admitted to being unaware that all staff, not just nursing department staff, required NA Registry checks. This lack of awareness contributed to the failure to comply with the established procedures, resulting in the hiring of staff without the necessary background and registry checks.
Failure to Implement Accurate Baseline Care Plan
Penalty
Summary
The facility failed to implement an accurate baseline care plan for a resident within 48 hours of admission, as required by their policy. The baseline care plan did not address the resident's Stage II sacral wound, which was a necessary intervention for their immediate health needs. The facility's policy mandates that a baseline care plan should include instructions for effective, person-centered care and meet professional standards of quality care. However, the omission of the wound care intervention in the baseline care plan indicates a failure to adhere to these standards. The resident in question was admitted with multiple diagnoses, including unspecified atrial fibrillation, chronic kidney disease stage 4, heart failure, hypertension, and diabetes mellitus. Additionally, there was a physician's order for daily wound care for a Stage II sacral wound, which was not included in the baseline care plan. Interviews with the Director of Nursing and the Administrator confirmed that the baseline care plan should have included the resident's immediate needs, such as wound care, and should have been individualized and signed by the resident or their representative.
Deficiencies in Care Plan Implementation for Residents
Penalty
Summary
The facility failed to implement comprehensive care plans with specific interventions for four residents, leading to deficiencies in addressing their individual needs. Resident #4 experienced a significant weight loss of 11.62% over six months, yet the care plan did not include specific interventions to address this issue. Despite having orders for mirtazapine as an appetite stimulant and monthly weight monitoring, the care plan lacked tailored strategies to manage the resident's weight loss. Resident #5 had a diagnosis of an unstageable wound on the left buttock, with orders for daily cleansing and application of Santyl and ABD pads. However, the care plan did not include specific interventions to address the wound care needs. Similarly, Resident #12's care plan failed to address pain management and anticoagulant use, despite having orders for hydrocodone-acetaminophen for pain and apixaban for anticoagulation. Resident #38 experienced a significant weight loss of 10.42% within 30 days, yet the care plan did not include specific interventions to address this issue. The resident had orders for weekly weights and a regular diet, but the care plan lacked individualized strategies to manage the weight loss. Interviews with the Director of Nursing and the Administrator confirmed that the care plans should have reflected the residents' individualized care needs, including weight loss, wound care, pain management, and anticoagulant use.
Failure to Follow Physician's Orders for Oxygen and Wound Care
Penalty
Summary
The facility failed to adhere to physician's orders for oxygen administration for two residents and wound care for another resident. Resident #3, diagnosed with chronic obstructive pulmonary disease and chronic respiratory failure, was observed receiving oxygen at 8 liters per nasal cannula, contrary to the physician's order of 6 liters. The resident reported requesting an increase in oxygen from a staff member, which was not followed by a check of the resident's oxygen level or consultation with a physician. Resident #5, with a diagnosis including an unstageable wound, was subject to improper wound care. The physician's order required Santyl to be applied directly to the wound, but the LPN applied it to a non-adherent dressing instead. This practice had been ongoing for three weeks, as confirmed by the LPN during an interview. Resident #14, with multiple diagnoses including COPD and Parkinson's disease, was observed receiving oxygen at 4 liters per nasal cannula, despite a physician's order for 6 liters. The resident was unaware of the correct oxygen setting, and the staff did not verify the oxygen concentrator settings as per the physician's orders. Interviews with the Director of Nursing and the Administrator confirmed that staff were expected to follow physician's orders and check oxygen levels before making any changes.
Failure to Implement RD Recommendations and Conduct Nutritional Assessments
Penalty
Summary
The facility failed to obtain a physician's order for a house supplement recommended by the registered dietician (RD) and did not ensure the RD completed a nutritional assessment for residents experiencing significant weight loss. This deficiency affected four residents, each of whom experienced severe weight loss over a specified period. The facility's policies on nutritional assessment and weight monitoring were not adhered to, as evidenced by the lack of timely RD assessments and the absence of physician orders for recommended supplements. Resident #4 experienced a severe weight loss of 11.62% over six months. Despite the RD's recommendation for a house supplement three times a day, there was no physician's order for this supplement, and the resident did not consistently receive it during meals. Similarly, Resident #24 had a severe weight loss of 6.1% within 30 days, with a recommendation for a daily house supplement that was not ordered or provided. Resident #34 experienced a severe weight loss of 11.2% over three months, with a similar lack of follow-through on the RD's recommendation for a daily supplement. Resident #38 had a severe weight loss of 10.42% within 30 days, with no physician's order for the recommended twice-daily supplement. Interviews with facility staff, including the Dietary Manager, Director of Nursing, and Administrator, revealed communication issues and procedural lapses. The RD's recommendations were not promptly addressed, and the RD's visits were not aligned with the facility's operational hours, limiting effective communication and follow-up. The RD only assessed residents with weight loss, contrary to the facility's policy requiring comprehensive nutritional assessments. These deficiencies highlight a systemic failure in the facility's nutritional management and communication processes, impacting the residents' health and well-being.
Failure to Reconcile Narcotics at Shift Changes
Penalty
Summary
The facility failed to ensure that staff reconciled narcotics at each shift change for two sampled medication carts, which had the potential to affect all residents. The facility's policy on controlled substances, revised in November 2022, mandates that controlled substance inventory be monitored and reconciled to identify loss or potential diversion. This process involves the nurse coming on duty and the nurse going off duty making the count together and documenting any discrepancies. However, the review of the 100 Hall Certified Medication Technician (CMT) Narcotic Count Log revealed numerous missed opportunities for reconciliation across various shifts from October 2024 to January 2025. Similarly, the review of the 200 Hall CMT Narcotic Count Log showed a significant number of missed reconciliations during the same period. Interviews with staff, including an LPN, the Director of Nursing (DON), and the Administrator, confirmed that the reconciliation should be conducted by the off-going and on-coming staff at each shift change. Despite this, the logs indicated consistent failures to perform the required reconciliations, highlighting a systemic issue in adhering to the facility's policy on controlled substances.
Failure to Monitor and Adjust Psychotropic Medication Regimen
Penalty
Summary
The facility failed to monitor the drug regimen for unnecessary medications by not ensuring that PRN psychotropic medication orders were limited to 14 days unless a specific duration and clinical rationale were provided. This deficiency was observed in two residents, one of whom was part of the sample and another outside the sample. Additionally, the facility did not attempt gradual dose reductions (GDR) for four residents, and there was a lack of appropriate diagnosis for the use of a psychotropic medication in one resident. The facility's policy required that residents using psychotropic medications receive GDR unless clinically contraindicated, and that the physician order appropriate tapering of medications as indicated. The facility's consultant pharmacist was responsible for reviewing the medication regimen of each resident at least monthly and providing a written report to the attending physicians for any identified non-life-threatening medication irregularities. However, the facility failed to address the pharmacy recommendations with the physician for several residents. For instance, recommendations to change dosages of medications for residents were not signed or dated by the physician, and the facility did not ensure that these recommendations were completed as they should be. Furthermore, there was no documentation of a specific duration or clinical rationale provided by the physician for the continuation of PRN medications beyond 14 days. Interviews with the Director of Nursing (DON) and the Administrator revealed that there was a system failure in ensuring that pharmacy recommendations were addressed in a timely manner. The DON expected a 14-day stop date to be ordered for PRN psychotropic medications, and the Administrator expected pharmacy recommendations to be reviewed, signed, and dated within a reasonable time frame to ensure compliance. Despite these expectations, the facility did not follow through with the necessary actions to address the deficiencies identified in the medication regimen reviews.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for three residents, leading to deficiencies in infection prevention and control. For Resident #5, EBP signage was not posted outside the room, and the LPN did not wear an isolation gown while performing wound care. The LPN was unaware that PPE was required for this resident until after the care was completed. Similarly, for Resident #191, EBP signage was also missing, and the RN did not wear an isolation gown. The RN failed to change gloves and perform hand hygiene after handling a bloody wound, indicating a lack of adherence to proper infection control protocols. For Resident #12, although EBP signage was posted and the RN initially donned an isolation gown and gloves, the RN stepped out into the hallway without removing the gown and gloves or performing hand hygiene, before returning to complete the wound care. This action breached the infection control protocol, as the RN should have removed the PPE and performed hand hygiene before leaving the resident's room. The Director of Nursing was unaware of the missing EBP signage for Residents #5 and #191, and acknowledged that staff should use gowns and gloves for residents on EBP and remove them before exiting the room.
Delayed Care Plan Implementation Due to EMR Transition
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents within the required timeframe, as mandated by their policy. The policy specifies that a comprehensive person-centered care plan should be developed within seven days after the completion of the Minimum Data Set (MDS) and no more than 21 days after admission. However, for two residents, no care plans were found in their medical records by the time of the review. Resident #1, who was admitted with multiple diagnoses including coronary artery disease, dementia, and arthritis, exhibited behaviors such as delusions and wandering, which placed them at significant risk. Similarly, Resident #2, admitted with conditions such as anemia, dementia, and hypertension, also showed delusional and wandering behaviors. Despite these needs, their care plans were not completed in the stipulated time. Interviews with facility staff, including the Director of Nurses and the MDS coordinator, revealed that the delay in care plan development was attributed to the transition to electronic medical records (EMR), which began on July 1, 2024. The MDS coordinator acknowledged that care plans were behind schedule or not completed due to this transition. The facility's administrator also confirmed that the transition to EMR was the reason for the delay in care plan completion, acknowledging that all residents should have a care plan within the specified timeframe.
Failure to Follow Physician's Orders for Multiple Residents
Penalty
Summary
The facility failed to adhere to physician's orders for four residents, leading to deficiencies in care. Resident #1 had orders for Medihoney and bordered foam to be applied to the coccyx daily and weekly skin assessments, which were not consistently documented or performed. Similarly, Resident #2's orders for Triad ointment application and UAD flushes were not followed as prescribed, with several missed opportunities for care and documentation. Resident #3 experienced significant lapses in care, with orders for lanolin ointment application, weekly weights, and pressure ulcer risk assessments not being fulfilled. Observations revealed dry, flaky skin and wounds that were not being treated according to the prescribed regimen. The resident reported that no lotions or creams had been applied to their legs or feet for some time, indicating a lack of adherence to the care plan. Resident #5's care was also compromised, with orders for Toprol XL not being properly documented and administered, and changes to oxygen tubing and distilled water in the concentrator not being completed as required. These failures in following physician's orders and documenting care reflect a systemic issue within the facility, as confirmed by interviews with staff and administration.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 27 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Licking
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Houston House | 13.6 mi | ★★★★★ | 8 | 0 |
| Seville Care Center | 19.7 mi | ★★★★★ | 4 | 0 |
| Salem Memorial District Hospital | 19.7 mi | ★★★★★ | 3 | 0 |
| Salem Care Center | 20.9 mi | ★★★★★ | 12 | 0 |
| Kabul Nursing Homes Inc | 28.8 mi | ★★★★★ | 0 | 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.