Hickory Creek at Madison

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF812Sep 18, 2025

  Based on observation and interview, the facility failed to ensure the kitchen was clean and sanitary during 3 of 3 kitchen observations. This deficient practice had the potential to affect 33 of 33 residents who received meals and snacks in the facility.Findings included:1.During the initial tour of the kitchen with [NAME] 4, on 9/14/25 at 9:30 a.m., the following concerns were observed: -Both the reach in refrigerator and the reach in freezer appliances had a moderate amount of food particles on the bottom inside and had streaks and brown spots which ran down the length of the doors.-A gallon jar of buttermilk salad dressing inside the refrigerator had a loose lid and multiple streaks of salad dressing which ran down the outside of the jar.-An uncooked pork loin was sitting in water on… […]

• No harm, potential for more than minimal, patternF727Sep 15, 2023

  Based on record review and interview, the facility failed to schedule 8-hour consecutive RN coverage for 6 of 6 months reviewed. (April, May, June, July, August and September 2023). This had the potential to affect all 31 residents currently residing in the facility. Findings include: Review of the April to September 2023 Licensed Nursing schedule indicated the following days were short of 8 hours consecutive RN coverage: April: Saturday 4/1 = only 2 hour RN coverage scheduled Sunday 4/2 = only 2 hour RN coverage scheduled Saturday 4/8 - only 5 hour RN coverage scheduled Sunday 4/9 = only 4 hour RN coverage scheduled Saturday 4/22 = only 5 hour RN coverage scheduled Sunday 4/23/= only 2 hour RN coverage scheduled May: Saturday 5/6 = only 2 hour RN coverage scheduled Sunday 5/7 = only 2… […]

• No harm, potential for more than minimal, isolatedF761Sep 18, 2025

  Based on observation, record review, and interview, the facility failed to ensure appropriate pharmacy and order labeling was on the insulin pens (Residents 18 and 24), and the removal of unused insulin pens (Residents 14 and 18) for 3 of 5 residents reviewed for Medication Storage. Findings include: 1.a. During an observation on 9/16/25 at 1:30 p.m., of medications in the Purple Medication Cart, Resident 18's Novolog pen had no label for the pharmacy and physician's orders on the packaging. The admission Minimum Data Set (MDS) assessment, dated 8/25/25, indicated the resident was cognitively intact. She had received four hypoglycemic (insulin) injections in the last 7 days. The record for Resident 18 was reviewed on 9/16/25 at 2:02 p.m. […]

• No harm, potential for more than minimal, isolatedF842Sep 18, 2025

  Based on observation, record review, and interview, the facility failed to ensure the accuracy of weekly skin assessments for 1 of 12 residents reviewed for resident records. (Resident 3)Finding included:The record for Resident 3 was reviewed on 9/15/25 at 9:01 a.m. The resident's diagnoses included, but were not limited to, chronic atrial fibrillation, essential (primary) hypertension, pain, neuromuscular dysfunction of bladder, Vitamin D deficiency, atrophic disorder of skin, tremor, unspecified protein-calorie malnutrition, dysphagia, and muscle weakness. The care plan, dated 6/3/15 with a review date of 8/4/25, indicated the resident was at risk for skin breakdown due to some sensory impairment that limited ability to feel pain/discomfort in 1 or 2 extremities. […]

• No harm, potential for more than minimal, isolatedF695Oct 25, 2024

  Based on observation, record review, and interview, the facility failed to ensure oxygen concentrator filters were maintained for 3 of 5 residents reviewed for respiratory care. (Residents 16, 29, and 21) Findings include: 1. a. During an observation on 10/21/24 at 11:15 a.m., Resident 16's bilateral oxygen concentrator filters were completely (100 percent) covered with a white powdery substance. The humidifier bottle was sitting on the floor. During an observation on 10/22/24 at 10:00 a.m., Resident 16's bilateral oxygen concentrator filters were completely covered with a white powdery substance. During an observation with the Director of Nursing (DON) on 10/23/24 at 11:05 a.m., Resident 16's bilateral oxygen concentrator filters were completely covered with a white powdery substance. […]