Inspection Reports for
Hickory Creek at Sunset

This citation relates to Complaint IN00451216.

The facility failed to ensure a resident was safely transported in her wheelchair, resulting in a fall and nasal fracture. The incident occurred when the resident's foot caught on a dip in the floor while being pushed in a wheelchair without foot pedals. The deficient practice was corrected prior to the survey with implementation of foot pedal use and staff training.

Complaint IN00451216 was substantiated with federal/state deficiencies cited. Complaint IN00451961 had no deficiencies related to the allegations.

The facility failed to ensure a resident was safely transported in her wheelchair, resulting in a fall and nasal fracture for one resident. The incident involved the resident's foot catching on a dip in the floor while being pushed in a wheelchair without foot pedals, causing the resident to fall and sustain injuries. The deficient practice was corrected prior to the survey.

The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included failure to maintain automatic sprinkler systems per NFPA 25, use of extension cords as substitutes for fixed wiring, and failure to ensure the oxygen trans-filling room door latched properly.

Complaint IN00442274 - No deficiencies related to the allegations were cited. Complaint IN00442280 - Federal/State deficiencies related to the allegations were cited at F550 (Resident Rights).

The facility was found deficient in ensuring resident rights during meal service, accuracy of Minimum Data Set (MDS) assessments, proper medication labeling and storage, and hand hygiene during meal service. Complaint IN00442274 had no deficiencies, while Complaint IN00442280 resulted in deficiencies related to resident rights.

This citation relates to Complaint IN00442280. The complaint involved Resident B's meal being delayed despite prior request for a hamburger substitute, and the resident was not offered alternative food while waiting.

The facility failed to ensure the dignity of Resident B during meal service when her requested meal substitute was delayed, and she was not offered alternative food while waiting. Interviews with the resident, Certified Food Manager, and Executive Director confirmed the delay and lack of offered alternatives.

This citation relates to Complaint IN00442280 regarding the dignity of a resident during meal service and medication storage and labeling.

The facility failed to ensure the dignity of a resident during meal service, proper handwashing technique by staff during meal service, and proper labeling and disposal of medications and biologicals. Specific issues included delayed meal service for a resident, improper handwashing by a Nursing Assistant in Training, and undated or improperly stored medications.

This citation relates to Complaint IN00435710. The complaint involved Resident G being left unattended in the shower room multiple times, lack of trauma-informed care, failure to assist with transportation from a hospital appointment, and failure to honor dietary preferences.

The facility failed to provide appropriate mental health services and trauma-informed care to Resident G, left the resident unattended multiple times in the shower room, failed to assist with transportation from a hospital appointment, and did not honor the resident's dietary preferences and dislikes. Documentation and care plans were lacking in these areas.

Complaint IN00435710 was substantiated with federal/state deficiencies cited at F742, F778, and F806. Complaints IN00436745, IN00437354, and IN00436109 had no deficiencies related to the allegations.

The facility was found deficient in ensuring appropriate mental and psychosocial services for a resident with PTSD and anxiety, assisting a resident with transportation arrangements from a hospital appointment, and honoring a resident's dietary dislikes and food preferences. The resident experienced psychosocial distress due to being left unattended in the shower room multiple times, was left without transportation after a hospital MRI appointment, and was served foods he could not tolerate despite communicating his preferences.

The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included failure to conduct preventative maintenance for battery-operated smoke alarms according to manufacturer's instructions, installation of mixed sprinkler head types within a smoke compartment, and incomplete documentation of sprinkler system inspections and generator load testing.

The complaint investigation focused on failure to maintain resident dignity, failure to provide incontinence care, improper respiratory care, medication errors, kitchen hygiene issues, and inaccurate staffing reporting.

The facility failed to maintain resident dignity by not changing a resident after an incontinence episode before feeding, failed to provide incontinence care for dependent residents, failed to properly store respiratory equipment and follow oxygen orders, had medication administration errors related to insulin, and failed to ensure proper kitchen hygiene and linen handling. Staffing reporting was also found inaccurate for one quarter.

Complaint IN00413927 was investigated and no deficiencies related to the allegations were cited.

The facility was found deficient in multiple areas including resident dignity and incontinence care, insulin administration errors, respiratory care, and food safety practices. Complaint allegations were not substantiated. Corrective actions and staff education plans were outlined.

The facility failed to ensure a timely referral for a PASRR re-evaluation for a resident with new mental health diagnoses, failed to monitor dishwasher sanitization properly for two months, and failed to ensure proper hand hygiene during dining service observations.