Inspection Reports for
Hickory Manor

Complaint #MO00254267 triggered the investigation. Resident #1 reported not having a shower in the past ten days and frequently going without showers for ten to fourteen days. Staff interviews confirmed shower schedules and procedures, but documentation and follow-up were inadequate.

The facility failed to provide showers for one resident (Resident #1) out of four sampled residents, despite the resident's request and scheduled shower days. Observations and interviews confirmed the resident had not received showers as frequently as required, resulting in an unkempt appearance.

The facility failed to complete criminal background checks and nurse aide registry checks for several staff prior to hire, did not implement accurate baseline and comprehensive care plans for multiple residents, failed to follow physician orders for oxygen and wound care, did not ensure timely dietary assessments and house supplement orders for residents with significant weight loss, failed to reconcile narcotics at each shift change, did not limit PRN psychotropic medication orders to 14 days or provide gradual dose reductions, and failed to implement enhanced barrier precautions during wound care.

Complaint #MO241812. The complaint involved failure to develop and implement care plans timely for residents, substantiated by interviews and record reviews.

The facility failed to develop and implement comprehensive care plans within seven days after completion of the comprehensive assessment and no more than 21 days after admission for two residents out of five sampled. The care plans were behind due to the transition to electronic medical records (EMR).

The visit was complaint-related with substantiation indicated by the findings of failure to follow physician's orders for multiple residents, resulting in missed treatments and documentation errors.

The facility failed to follow physician's orders for wound care, medication administration, and documentation for multiple residents, resulting in missed treatments, assessments, and medication errors. The deficiencies were determined to cause minimal harm or potential for actual harm affecting a few residents.

The facility was found deficient in multiple areas including incomplete and inaccurate resident assessments, failure to implement individualized care plans, failure to follow physician orders, lack of proper assessments and consents for bed rails and trapeze use, failure to post nurse staffing information, inadequate pharmacist medication regimen reviews especially related to antipsychotic medications, improper garbage disposal, failure to provide and document vaccinations for pneumococcal, influenza, and COVID-19, and failure to provide required annual nurse aide training.

Complaint #MO00226392 regarding failure to notify resident's responsible party after falls and emergency room transfer. The complaint was substantiated based on interviews and record reviews.

The facility failed to notify the responsible party of Resident #1 after two falls resulting in injuries, including a head injury requiring emergency room transfer. Staff did not document notification attempts or successful notifications to the resident's representative as required by facility policy.

The facility was found deficient in providing timely showers and grooming assistance to residents, preventing medication errors related to insulin pen priming, maintaining food safety standards including proper hair coverings and food storage, ensuring tuberculosis screening for staff and residents, and maintaining kitchen cleanliness and equipment.