Hickory Creek at Sunset

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF812Sep 11, 2024

  Based on observation, interview, and record review, the facility failed to ensure proper handwashing procedure during meal service for 1 of 2 dining observations. Findings include: During an observation of the lunch meal service, on 9/5/24 at 12:27 p.m., Nursing Assistant in Training (NAIT) 5 was observed to wash hands for less than 20 seconds and to turn off the water faucet without using a paper towel as a barrier. She then proceeded to serve trays to multiple residents in the dining room. During an interview, on 9/10/24 at 3:08 p.m., the Director of Nursing (DON) indicated all staff should all be aware of proper handwashing technique. […]

• No harm, potential for more than minimal, patternF812Jul 28, 2023

  Based on observation, interview, and record review, the facility failed to ensure proper handling of linens used in the kitchen and to ensure paper towels were available for proper handwashing, during 1 of 2 kitchen observations. This deficient practice had the potential to effect 36 of 36 residents who received food from the kitchen. Findings include: 1. On 7/24/23 at 9:46 a.m., Housekeeper 6 was observed carrying clean linen into the kitchen area. The linens were being held up against the housekeeper's uniform. 2. The initial kitchen observation was completed with Cook 7, on 7/24/23 at 10:04 a.m. While washing their hands at the handwashing sink, the visitor observed there were no paper towels available to dry their hands and to turn off the water at the sink. […]

• No harm, potential for more than minimal, patternF584May 26, 2021

  Based on observation, interview, and record review, the facility failed to ensure meals were removed from trays when served for 16 of 16 residents observed served lunch, and food was placed in front of residents who required assistance to eat during 2 of 2 dining room observations (Residents 14 and 11). Findings include: 1. During a dining observation, on 5/20/21 at 12:05 p.m., 16 residents were served lunch in the main dining room. All residents' food remained on the serving trays. Resident 14 was not placed at a dining room table and was assisted to eat by Housekeeper 11. His food was placed on a bedside table to the side and behind him. He was unable to see the food. Resident 11 was assisted to eat by Certified Nursing Assistant (CNA) 6. […]

• No harm, potential for more than minimal, patternF812May 26, 2021

  Based on observation, interview, and record review, the facility failed to ensure appropriate food storage, labeling, and dating in the kitchen during 1 of 2 random kitchen observations, and to ensure hand hygiene was performed for 8 of 8 residents who received hall trays (Residents 26, 32, 17, 15, 188, 2, 21, and 19). Findings include: 1. During an initial kitchen tour, on 5/20/21 at 10:13 a.m., a reach in cooler contained an open container of lite mayonnaise with a used by date of 5/18/21, an open container of ranch dressing with no open or use by dates, and an open container of cocktail sauce with an expiration date of 5/1/21. A reach freezer contained an open, uncovered package of 15 biscuits. […]

• No harm, potential for more than minimal, isolatedF550Jul 23, 2026

  Based on record review and interview, the facility failed to honor a resident's request to go to the hospital via Emergency Medical Service and timely provide paperwork for continuity of care, potentially causing a delay in treatment for 1 of 4 residents reviewed for resident rights and quality of care. (Resident B) Findings include:An intake document, dated 6/19/26 at 6:09 p.m., indicated a 911 call was received from a patient who was on the front walk of the facility due to their oxygen running out. Staff refused to assist with moving the patient or assisting with patient at all because she contacted 911 herself. It was indicated this was considered AMA [against medical advice]. They attempted to convince the patient not to go to the hospital, despite critical oxygen levels. […]