Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Manor during CMS and state inspections, most recent first.
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 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
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 8 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
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 | ★★★★★ | 1 | 0 |
| Seville Care Center | 19.7 mi | ★★★★★ | 4 | 0 |
| Salem Memorial District Hospital | 19.7 mi | ★★★★★ | 3 | 0 |
| Salem Care Center | 20.9 mi | ★★★★★ | 0 | 0 |
| Kabul Nursing Homes Inc | 28.8 mi | ★★★★★ | 7 | 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 July 2026) and official state health department websites.