Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hickory House Nursing Home during CMS and state inspections, most recent first.
The facility failed to notify the State Ombudsman of emergency hospital transfers for seven residents. Records showed residents were sent to the hospital for conditions including a hip fracture, stroke-like symptoms, altered mental status, hypotension, shortness of breath, an unresponsive episode, and respiratory failure, but there was no evidence the required notifications were made; the NHA confirmed the omissions.
Failure to Timely Notify Provider and Representative of Significant Change in Condition: The facility did not timely notify the MD and resident representative when two residents had significant changes in condition. One resident with dementia, RA, and HTN developed confusion, worsening vision, altered mental status, tremors, and left-sided weakness before hospital transfer, with no timely MD or POA notification documented. Another resident with CAD, PVD, DM, renal insufficiency, and anticoagulant/antiplatelet use had a fall followed by SOB, abnormal VS, low O2 sat, and later ER transfer, but provider notification was delayed.
A resident’s quarterly MDS incorrectly indicated that hospice care was not being received, even though the physician’s orders included hospice and hospice notes showed admission to Holisticare hospice. The NHA confirmed the MDS was marked incorrectly.
A resident with PAD and right leg ischemia had a right ankle wound that was not properly and comprehensively assessed, with the wound type initially documented as unknown despite drainage, slough, and later review of hospital records showing it was venous. Another resident with Parkinson’s disease had an active order for Nuplazid for Parkinson-related psychosis, but the med was unavailable for multiple scheduled doses and was repeatedly not administered while staff documented prior authorization, insurance, and cost issues.
Improper Foley Bag Positioning: A resident with an indwelling urinary catheter was observed with the catheter tubing/drainage bag on the floor while in bed and later while seated in a wheelchair. Facility policy required the collecting bag to remain below the bladder and off the floor, and an LPN, another staff member, and the NHA confirmed the bag should not have been on the floor.
A resident, cognitively intact and on hospice care, had an order for morphine sulfate concentrate 20 mg/mL to be given as 5 mg PO q2h PRN for pain/SOB, with non-pharmacological interventions attempted first. Facility policy required adherence to the 10 Rights of Medication Administration and preparedness for opioid-induced respiratory depression. Despite this, documentation on the controlled medication record showed the resident was given 1 mL of morphine concentrate instead of the prescribed 0.25 mL. Nursing notes and an employee statement confirmed that an excess dose was administered, after which the resident developed increased lethargy and decreased BP and required two IM doses of Narcan, with subsequent improvement and return to baseline.
A resident filed a grievance alleging that a CNA was verbally disrespectful, threw a shirt at the resident, refused to assist with socks, and left the room without returning. The DON confirmed that this abuse allegation was not reported to the State agency as required by facility policy and state regulations.
A resident reported that a CNA spoke disrespectfully, threw a shirt at the resident, refused to help with socks, and left the room without returning. The DON confirmed that this abuse allegation was not fully investigated, as required by facility policy.
Surveyors found that three residents did not receive care according to physician orders, including administration of Midodrine and Metoprolol outside of specified blood pressure parameters and failure to adhere to a prescribed fluid restriction for a resident with CHF. These deficiencies were confirmed through record review and staff interviews.
A resident with a physician's order for oxygen therapy via nasal cannula did not have their equipment changed as directed, with observations showing the cannula was not replaced weekly and was visibly soiled, contrary to facility policy and medical orders.
The facility failed to thoroughly investigate incidents involving three residents. A resident with dementia was found with a bleeding wrist, but the incident report lacked key details. Another resident with severe cognitive impairment reported feeling unsafe and alleged abuse, but no staff statements were taken. A third resident had a pen found in their rectum, but the investigation did not include interviews or contact with the hospital. The facility's investigations were confirmed to be incomplete.
The facility failed to follow physician's orders and notify the physician of missed medications for three residents. One resident missed doses of Vancomycin due to unavailability, another received Coreg despite a low heart rate, and a third was given Midodrine outside of ordered parameters. The DON confirmed these deficiencies.
A resident with severe cognitive impairment and a history of dementia and CVA experienced two falls in one day due to inadequate supervision and assistance. The resident, requiring two-person assistance for transfers, fell while attempting to enter a family van without proper assessment and later during a one-person transfer from a wheelchair to a bed, contrary to their care plan.
A resident with COPD and other respiratory conditions was receiving supplemental oxygen without a physician's order, contrary to the facility's policy. The resident had been on continuous oxygen since admission, but the order was only documented after several days, following confirmation by the DON.
A resident was given antibiotics for a probable UTI without a proper nursing assessment or lab confirmation. The decision was made after a phone call with a doctor, and the resident received antibiotics for five days without microbiological evidence. The DON and Nursing Home Administrator confirmed the lack of assessment and lab study.
Failure to Notify Ombudsman of Emergency Transfers
Penalty
Summary
The facility failed to notify the office of the state long term care ombudsman of emergency transfers for seven residents reviewed. Clinical records showed that Resident 2 was admitted to the hospital for a left hip fracture, Resident 3 was transferred for right-sided weakness and headache, Resident 6 was transferred for altered mental status and left-sided weakness, Resident 21 was admitted for hypotension, Resident 101 was transferred for shortness of breath, Resident 106 was transferred for an unresponsive episode, and Resident 108 was admitted for respiratory failure. For each of these residents, review of the clinical record and facility documentation failed to reveal evidence that the State Ombudsman’s office was notified of the transfer and hospital admission. The Nursing Home Administrator confirmed in interview that notification of the transfers and admissions for Resident 2, Resident 3, Resident 6, Resident 21, Resident 101, Resident 108, and Resident 106 was not sent to the State Ombudsman’s office as required.
Failure to Timely Notify Provider and Representative of Significant Change in Condition
Penalty
Summary
The facility failed to timely notify the resident's representative and medical provider of significant changes in physical condition for two residents, resulting in hospitalization. Facility policy required notification of the resident's primary care provider and resident or resident representative when there was a change in condition or status, and immediate consultation with the physician for a significant change in physical, mental, or psychological status. Resident 6's record showed diagnoses including hypertension, non-Alzheimer's dementia, anxiety, depression, and rheumatoid arthritis, and the resident was cognitively intact, ambulatory with a rolling walker, and partially dependent for activities of daily living. Nursing notes documented a sudden change in mental status with confusion, inability to answer simple questions, and worsening vision, followed by altered mental status, tremors, stiffness, inability to voice anything, right-sided focus, tachycardia, low oxygen saturation, and later inability to move the left arm or left leg. The record showed no notification to the physician or POA after the initial change in mental status on January 9, 2026, and no notification on the morning of January 11, 2026 when the resident's condition had further declined before transfer to the hospital. Resident 101's admission MDS showed the resident was cognitively intact and required moderate assistance with activities of daily living, with diagnoses including coronary artery disease, hypertension, peripheral vascular disease, renal insufficiency, diabetes mellitus, and recent gall stone removal, and medications including anticoagulants and antiplatelets. After a fall, nursing documentation described the resident as shaky, short of breath, with elevated blood pressure, irregular respirations, low oxygen saturation, and later being found on the floor with oxygen started. The record noted that family and the physician were to be notified, but the provider was not called until several hours later, and the resident's wife later requested transfer to the ER, after which the resident was sent out and hospital documentation referenced pulmonary edema.
Inaccurate MDS Hospice Status
Penalty
Summary
The facility failed to ensure that Resident 79’s assessment accurately reflected the resident’s status. Review of the quarterly MDS dated February 18, 2026 showed in section O0110, Special Treatments, Procedures, and Programs, that the resident was not receiving hospice care. However, the resident’s physician’s orders included hospice, and hospice notes showed that Resident 79 was admitted to Holisticare hospice on November 21, 2025. During an interview on May 14, 2026 at 1:28 p.m., the Nursing Home Administrator confirmed that the MDS assessment was marked incorrectly.
Wound Assessment Not Completed and Ordered Parkinson’s Medication Unavailable
Penalty
Summary
The facility failed to appropriately assess a wound for one resident with right leg ischemia and peripheral artery disease. On admission, the resident had an opening on the right outer ankle that was documented as an open area/wound with redness and drainage, and an Adaptec dressing was ordered. A later wound assessment by a licensed nurse documented the right lateral ankle wound as 0.7 x 0.6 x 0.3 cm with 100% slough, and a treatment plan was ordered to cleanse with normal saline, pack with Iodoform ribbon, and cover with a foam dressing. The wound type was identified as other, wound of unknown origin. During interview, the licensed nurse stated that wound assessment should include wound type, measurements, drainage, and wound description, and confirmed the wound type should have been appropriately identified during the initial assessment and later assessment. The nurse also stated that the wound type was identified as venous only after review of the resident’s hospital records, and that those records were reviewed after the surveyor asked about the wound type. The facility therefore did not properly and comprehensively assess the resident’s right lateral ankle wound. The facility also failed to ensure that another resident’s ordered Nuplazid was available and administered. The resident had Parkinson’s disease without dyskinesia and an active physician order for Nuplazid 34 mg daily for Parkinson disease associated psychosis. The eMAR showed multiple missed administrations over several weeks, and nursing notes repeatedly documented that the medication was not available because prior authorization was pending or because of insurance and cost issues. The notes also showed repeated communication with the CRNP and office staff about the missing medication, and the medication was ultimately discontinued after it remained unavailable.
Improper Foley Bag Positioning
Penalty
Summary
Appropriate care to prevent urinary tract infections was not provided for one of four residents reviewed, Resident 103, who had an indwelling urinary catheter. The facility policy titled Indwelling Urinary Catheter (Foley) Management, dated September 4, 2025, stated that the collecting bag must be kept below the level of the bladder at all times and not rested on the floor. However, on May 11, 2026, at 12:15 p.m., Resident 103 was observed in a low bed with the catheter tubing on the floor, and on May 12, 2026, at 2:00 p.m., the resident was observed sitting in a wheelchair with the catheter touching the floor. Employee 3 confirmed on May 11, 2026, at 12:17 p.m. that the catheter drainage bag was on the floor and should not have been, and Employee 4 confirmed on May 12, 2026, at 2:05 p.m. that the drainage bag was on the floor and should not have been. The Nursing Home Administrator also confirmed these findings on May 14, 2026, at 1:26 p.m.
Significant Morphine Dosing Error Requiring Narcan Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from a significant medication error involving morphine administration. Facility policy on Administration of Medications required staff to follow the 10 Rights of Medication Administration, including the right drug, right resident, and right dose, and the policy on Opioid-Induced Respiratory Depression required preparedness to address opioid-related emergencies. The resident involved was cognitively intact, dependent on staff for ADLs, and admitted for long-term care, later admitted to hospice. A physician’s order on the resident’s MAR directed that morphine sulfate concentrate 20 mg/mL be given as 5 mg by mouth every 2 hours PRN for pain or shortness of breath, with documentation of three non-pharmacological interventions prior to use for pain. Despite this order, the Controlled Medication Utilization Record showed that the resident received 1 mL of morphine concentrate instead of the prescribed 0.25 mL, resulting in a dose above the ordered amount. A nursing progress note documented that the resident received an excess dose of morphine concentrate, with initial vital signs, neurological status, and mentation within normal limits, and an employee statement confirmed that the nurse administered more than the prescribed dosage. A subsequent nursing note recorded that the resident then exhibited increased lethargy and decreased blood pressure, and Narcan was administered intramuscularly twice for possible side effects from the increased morphine dose, after which blood pressure and mentation improved. Later documentation indicated the resident was monitored with vital signs within normal limits and remained responsive, and a physician note confirmed that the resident had received a morphine dose above the prescribed amount, became lethargic with decreased blood pressure, was treated with Narcan, and returned to baseline.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving one resident. According to facility policy, any alleged violations involving neglect, abuse, or misappropriation of resident property must be reported immediately to the administrator and as required by state law. A grievance was filed by a resident stating that a CNA spoke to him disrespectfully, threw a shirt at him, told him to put it on, refused to help him put on socks, and then left the room without returning. The Director of Nursing confirmed that this abuse allegation was not reported to the State agency as required by policy and regulation.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving one resident. According to facility policy, any reported or suspected incident of abuse, neglect, or exploitation requires an investigation by the administrator or designee, with protective measures implemented as needed. Documentation review showed that a resident filed a grievance stating that a CNA spoke to him disrespectfully, threw a shirt at him, told him to put it on, refused to assist with putting on socks, and then left the room without returning. An interview with the Director of Nursing confirmed that this abuse allegation was not fully investigated, contrary to facility policy and regulatory requirements.
Failure to Follow Physician Orders for Medication and Fluid Restriction
Penalty
Summary
The facility failed to follow physician orders for three residents, resulting in deficiencies related to medication administration and fluid restriction. For one resident with hypotension, Midodrine was administered multiple times despite blood pressure readings exceeding the physician-ordered threshold for withholding the medication. Documentation showed that the medication was given on several occasions when the systolic blood pressure was above 125 mm/Hg, contrary to the order. Another resident with acute congestive heart failure and malnutrition had a physician order for a strict fluid restriction, but records indicated that the resident consistently received fluids in excess of the prescribed daily limit over several days. Additionally, a third resident with hypertensive chronic kidney disease received Metoprolol Succinate ER outside of the specified blood pressure and heart rate parameters on four occasions. These findings were confirmed through review of clinical records, medication administration records, and staff interviews.
Failure to Follow Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to follow a physician's order for oxygen therapy for one resident. According to the clinical record, the resident had a current order to receive oxygen via nasal cannula, with instructions for the cannula to be changed every night shift on Wednesdays. Facility policy also required oxygen supplies, including cannulas, to be changed weekly and when visibly soiled, and to be labeled with the resident's name and the date of setup or change. Observations on two consecutive days revealed that the resident's nasal cannula was dated from several weeks prior and was visibly soiled, with red-tinged nasal prongs and brownish-red dots on the wrapping. The resident confirmed regular use of the oxygen equipment while in the facility.
Failure to Investigate Incidents Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate incidents involving three residents, as required by their policy on reducing the threat of abuse and neglect. For Resident 2, who has a history of dementia, anxiety disorder, and major depressive disorder, an incident occurred where the resident was found with a bleeding cut on the wrist. The incident report lacked documentation identifying the nurse who treated the wound and did not include any witness statements. The Nursing Home Administrator confirmed that the investigation was incomplete. Resident 95, who has severe cognitive impairment, reported feeling unsafe and alleged physical abuse by two men, described as EMT staff. The facility's documentation did not include statements from staff who had contact with the resident, and the Director of Nursing confirmed the lack of a comprehensive investigation into the allegation of physical abuse. For Resident 155, admitted after a hip fracture repair, an incident was reported where a pen was found in the resident's rectum. The facility's investigation did not include interviews with staff or residents, nor did it contact the hospital or transport company involved in the resident's admission. The Nursing Home Administrator and Director of Nursing confirmed the investigation was not thorough.
Failure to Follow Physician's Orders and Notify of Missed Medications
Penalty
Summary
The facility failed to follow physician's orders and notify the physician of missed medications for three residents. Resident 9 had a physician's order for Vancomycin to treat C-diff, but the medication was not administered until the morning of the last day of the order, missing three doses due to unavailability. The physician was not notified of the missed doses until several days later. Resident 51 received Coreg, a beta blocker, despite having a heart rate below the ordered parameter on multiple occasions over several months. The clinical records indicated that the medication was administered with a heart rate of less than 60, contrary to the physician's order. Resident 95 was administered Midodrine, a medication for low blood pressure, outside of the ordered parameters, as it was given 13 times with a systolic blood pressure above 130. The Director of Nursing confirmed that the medication was administered outside of the ordered parameters. These deficiencies indicate a failure to adhere to physician's orders and to communicate effectively with physicians regarding medication administration issues.
Failure to Provide Adequate Supervision and Assistance Leads to Resident Falls
Penalty
Summary
The facility failed to provide appropriate assessment and supervision to prevent falls for a resident with severe cognitive impairment and a history of dementia and cerebral vascular accident. The resident required extensive assistance with two persons for transfers using a hemi walker, as documented in their care plan. On January 1, 2024, the resident was found on the floor outside the facility after attempting to transfer into a family van without the necessary assistance. The rehabilitation department was not notified to assess the resident's safety with car transfers, which contributed to the incident. Later that same day, the resident experienced another fall when an aide attempted a one-person pivot transfer from a wheelchair to a bed, despite the care plan indicating the need for a two-person assist. The aide lowered the resident to the floor after the resident slipped during the transfer. Interviews with the Director of Nursing confirmed that the resident was not provided with the required two-person assistance, leading to two falls in one day.
Lack of Physician Order for Oxygen Use
Penalty
Summary
The facility failed to ensure a physician order for oxygen use was in place for a resident, identified as Resident 205, who was receiving supplemental oxygen. The facility's policy on oxygen administration, revised in February 2024, requires a written order specifying the liter flow needed by the resident. Resident 205, diagnosed with Chronic Obstructive Pulmonary Disease (COPD), bronchiectasis with an acute lower respiratory infection, and pleural effusion, was observed receiving supplemental oxygen at two liters per minute (LPM) via nasal cannula. Despite the resident's need for continuous supplemental oxygen since admission, there was no active physician's order documented in the clinical records. Interviews with Resident 205 revealed that they had been using supplemental oxygen as needed at home and required continuous oxygen since being admitted to the facility. The Director of Nursing confirmed the absence of a physician's order for the resident's supplemental oxygen from the time of admission. It was only on May 31, 2024, that a physician's order was documented, specifying oxygen administration at two to four LPM, with instructions to titrate to maintain saturation above 90% and notify the physician if needs could not be met at four liters.
Unnecessary Antibiotic Administration Due to Lack of Assessment
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, Resident 79 was administered an antibiotic without a proper nursing assessment or laboratory confirmation of a urinary tract infection (UTI). The resident had reported symptoms of dysuria and was noted to have blood on his penis and in his brief. Despite these symptoms, there was no documented nursing assessment to confirm the signs and symptoms reported by the CNA, nor was there any laboratory testing conducted to confirm a UTI before the administration of antibiotics. The decision to prescribe antibiotics was made after a phone call with the doctor's office, where it was noted that it was a Friday afternoon and the resident was symptomatic. The resident was subsequently given Amoxicillin-Pot Clavulanate for five days based on a diagnosis of probable UTI, without any microbiological evidence to support this diagnosis. The Director of Nursing and the Nursing Home Administrator confirmed the lack of a nursing assessment and laboratory study to confirm the infection and its sensitivity prior to the administration of the antibiotics.
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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 Honey Brook
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tel Hai Retirement Community | 1.7 mi | ★★★★★ | 2 | 0 |
| Inn At Freedom Village,the | 5.9 mi | ★★★★★ | 0 | 0 |
| Zerbe Sisters Nursing Center, | 7.7 mi | ★★★★★ | 0 | 0 |
| St Martha Center For Rehabilitation & Healthcare | 9 mi | ★★★★★ | 3 | 0 |
| Newport Meadows Health And Rehabilitation Center | 10.8 mi | ★★★★★ | 2 | 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 October 2026) and official state health department websites.