Hickory Falls Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Hickory Falls Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600May 31, 2024

  Based on observations, record review, and resident, staff, NP and Law Enforcement Detective interviews the facility failed to protect a resident's right to be free from physical abuse when Nurse Aide (NA) #1 punched Resident #1 in the face. On 5/9/24 Resident #1 was sent to the Emergency Department (ED) for evaluation where it was noted the resident had significant bruising around the left eye and a small laceration at the corner of the left eye. A CT (computed tomography) scan of the head was completed and confirmed comminuted fractures (fracture in at least 2 places) of the left nasal bone, left maxillary sinus wall, left maxilla (the bone that forms the upper jaw) and left orbital rim (broken bone in the outer edge of the eye socket). Resident #1 returned to the facility on [DATE]. […]

• Immediate jeopardy, isolatedF600Sep 20, 2022

  Based on record review and staff interviews the facility failed to protect a resident from verbal and physical abuse when Nurse Aide (NA) #2 proceeded to provide care to a resident (Resident #257) while he was agitated and combative. NA #2 taunted, aggressively pushed, aggressively turned, slapped the resident on the hip, and grabbed his arms and held them on his neck resulting in the resident asking, are you trying to choke me, and leaving a bruise on his right hand and redness to his chest for 1 of 3 residents reviewed for abuse (Resident #257). […]

• Immediate jeopardy, isolatedF607Sep 20, 2022

  Based on record review, and staff interviews, the facility failed to intervene to stop verbal and physical abuse and/or failed to immediately call for assistance from administrative staff or licensed staff to stop the abuse. The facility policies and procedures failed to include reporting abuse to the state survey agency, APS and local law enforcement. The facility failed to report the abuse to APS and to the state survey agency, and local law enforcement within the required timeframes for 1 of 3 residents reviewed for staff to resident abuse (Resident # 257). Immediate Jeopardy began on 6/13/22 when the facility witnessed verbal and physical abuse and did not intervene to stop it, or immediately call for licensed staff or administrative staff to stop it. […]

• No harm, potential for more than minimal, patternF761May 20, 2021

  Based on observations and staff interviews, the facility failed to discard an undated opened multi-dose vial of influenza vaccine in 1 of 1 medication room, discard an opened single-dose vial of an injectable medication, undated and opened insulin pens, and loose pills in 5 of 5 medication carts (A hall, B hall, C hall, D hall and F hall). They also failed to store undated and unopened vials of insulin per manufacturer instructions and failed to secure a narcotics drawer in 1 of 5 medication carts (B hall). The findings included: a. An observation of the medication room with the Assistant Director of Nursing (ADON) on 5/20/21 at 7:15 AM revealed an opened and undated vial of influenza vaccine in the medication room refrigerator. Half of the vial was left available for use. […]

• No harm, potential for more than minimal, isolatedF842May 21, 2025

  Based on record review and staff, Nurse Practitioner and Medical Director interviews, the facility failed to maintain a complete and accurate medical record when identification of a new pressure injury and the completion of wound treatments were not documented in the medical record for 1 of 3 residents reviewed for accurate medical record (Resident #303). The findings included: Resident #303 was admitted to the facility on [DATE]. A physician's order dated 1/3/2025 read: Cleanse sacrum with wound cleanser, pat dry, apply betadine and secure with foam patch once a day was written by the Wound Nurse. […]