Hickory Creek at Columbus

In the surveyor’s words

From the most serious findings on record at Hickory Creek at Columbus, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Sep 9, 2021

  Based on interview and record review, the facility failed to provide adequate monitoring, assessment, and follow up care to a resident when management was notified by a Qualified Medication Aide there was a potential medication error. The nurse on duty failed to report to the oncoming shift of a significant change of a resident related to blood sugar monitoring. Resulting in the resident being found unresponsive the next morning with a blood sugar of 19. (Resident D) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began, on [DATE] at 10:03 p.m., when a moderately cognitive resident had a blood sugar check and a high blood sugar of 495 (normal blood sugar range was from 80 to 130 mg/dl). […]

• Actual harm, isolatedF697Jun 21, 2022

  Based on observation, interview, and record review, the facility failed to implement appropriate pain management interventions before or during a wound treatment resulting in the resident crying out, gritting her teeth, moaning, and grimacing during the treatment for 1 of 3 residents reviewed for pain management. (Resident 28) Findings include: During an observation on 06/21/22 at 11:07 A.M., RN 3 explained to Resident 28 that she was going to change the wound dressing on the resident's right heel. She washed her hands and donned gloves. RN 3 started to cut the dressing off the resident's foot when the resident started saying it hurts, it hurts. The resident's eyes were closed. She was gritting her teeth, moaning, and grimacing. […]

• No harm, potential for more than minimal, widespreadF838Jun 10, 2022

  Based on interview and record review, the facility failed to follow the facility-wide assessment based on the residents needs and the required resources to provide the care and services needed. This had the potential to affect 33 of 33 residents residing in the facility. Findings include: During an interview on 6/9/22 at 9:55 p.m., LPN (Licensed Practical Nurse) 2 indicated there were only two staff on duty, that shift, in the building. One LPN and a one CNA (certified nurse aide). During an interview on 6/9/22 at 9:59 p.m., CNA 3 indicated she was on the front porch, on a break, came back in and rounded the corner to the right, toward the hallway to the nurses station. When she did she saw Resident C with his arms around the LPN, who was in the floor. […]

• No harm, potential for more than minimal, patternF757Jul 12, 2021

  Based on observation, record review, and interview, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Residents 20, 13, 26, and 17) Findings include: 1. On 07/07/21 at 2:24 P.M., Resident 20 was observed sitting on a love seat in the hallway across from an entry door looking out the window. He was awake and alert and his speech was clear. A Quarterly MDS (Minimum Data Set) assessment, dated 05/26/21, indicated the resident was severely cognitively impaired. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had received insulin injections for seven of the seven days during the assessment review period. The July MAR/TAR (Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. […]

• No harm, potential for more than minimal, isolatedF656Sep 12, 2025

  Based on observation, record review, and interview, the facility failed to ensure care planned interventions were implemented for 2 of 12 residents reviewed for Care Plans. (Residents 19 and 7)Findings include:1. Resident 19's room was observed on 09/10/2025 at 1:35 P.M. The resident's call light was observed near her bed. The call light was white, and there was no bright colored tape attached to the call light.The resident was observed on 09/11/2025 at 9:07 A.M. The resident was in her room in bed. The resident's call light was within reach. There was no brightly colored tape attached to the call light. The resident's clinical record was reviewed on 09/10/2025 at 2:27 P.M. […]