Hickory House Nursing Home

In the surveyor’s words

From the most serious findings on record at Hickory House Nursing Home, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF628May 14, 2026

  Based on review of clinical records and interview with staff, it was determined that the facility failed to notify the office of the state long term care ombudsman of emergency transfers for seven out of seven residents reviewed (Resident 2, Resident 3, Resident 6, Resident 21, Resident 101, resident 108, and Resident 106,).Findings include:Review of Resident 2's Health Status Note dated January 17, 2026, at 3:00 p.m. reveals that the resident was admitted to the hospital for the treatment of a left hip fracture. […]

• No harm, potential for more than minimal, patternF610May 31, 2024

  Based on facility policy and procedure review, clinical record review, and staff interviews, it was determined the facility failed to thoroughly investigate incidents for three of 32 residents reviewed. (Residents 2, 95, and 155) Findings include: Review of facility policy and procedure titled Protection of Residents: Reducing the Threat of Abuse & Neglect, reviewed May 15, 2020, revealed when an incident of or suspected incident of resident abuse and/or neglect of unknown source, exploitation or misappropriation of resident property is reported the administrator/designee will investigate the occurrence. The administrator/designee will complete an Incident Report and will utilize the Incident Investigation Questionnaire Form to document the investigation. […]

• No harm, potential for more than minimal, patternF684May 31, 2024

  Based on clinical records review and staff interview, it was determined that the facility failed to follow the physician's orders and notify the physician of missed medications for three of the 24 residents reviewed (Residents 9, 51, and 95). Findings include: Review of Resident 9's physician order dated May 18, 2024, revealed an order for Vancomycin HCL (antibiotic) Oral Capsule 125 mg given one capsule by mouth every 12 hours for C-diff (An inflammation of the colon caused by the bacteria Clostridium difficile) until May 18, 2024. Review of Resident 9's clinical record including May 2024 Medication Administration Record revealed Vancomycin was not administered to the resident until the morning of May 18, 2024, missing three doses due to unavailability of the medication. […]

• No harm, potential for more than minimal, isolatedF580May 14, 2026

  Based on review of facility policy, clinical records, facility documentation, and staff interview, it was determined that the facility failed to timely notify the resident's representative and medical provider of significant changes in physical condition resulting in hospitalization for two out of seven residents reviewed (Resident 6 and Resident 101).Findings include:A review of facility policy Changes in Resident's Condition or Status revised August 29, 2025, revealed that This facility will notify .his/her primary care provider, and resident/resident representative of changes in the resident's condition or status.A facility must immediately. […]

• No harm, potential for more than minimal, isolatedF641May 14, 2026

  Based on clinical record review and staff interview, it was determined that the facility failed to ensure that resident assessments accurately reflect the residents' status for one of 22 residents reviewed. (Resident 79).Findings include:Review of Resident 79's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated February 18, 2026, revealed under section O 0110- Special Treatments, Procedures, and Programs, that Resident 79 was not receiving hospice care.Review of Resident 79's physician's orders revealed that the resident has an order for hospice.Review of Resident 79's hospice notes revealed that the resident was admitted to Holisticare hospice on November 21, 2025.Interview with the Nursing Home Administrator, on May 14, 2026, at 1:28p.m. […]