Inspection Reports for
Hickory Manor
209 HICKORY ST, LICKING, MO, 65542-9847
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
11.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
115% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
65% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 1
Date: May 28, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide showers to a resident as scheduled.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to provide showers for one resident as scheduled, resulting in minimal harm or potential for actual harm.
Report Facts
Residents affected: 1
Facility census: 39
Shower frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant (CNA) A | Interviewed regarding shower schedules and procedures. | |
| Licensed Practical Nurse (LPN) B | Interviewed regarding shower schedules and procedures. | |
| Director of Nurses (DON) | Interviewed regarding shower schedules, procedures, and follow-up. |
Inspection Report
Plan of Correction
Census: 39
Deficiencies: 1
Date: May 28, 2025
Visit Reason
The document is a plan of correction submitted following a survey conducted on 05/28/2025 regarding deficiencies found at Hickory Manor.
Findings
The facility failed to provide showers for one resident out of four sampled residents, despite policies and schedules indicating showers should be provided at least twice a week. Resident #1 had poor hygiene and incomplete shower documentation, indicating noncompliance with required care standards.
Deficiencies (1)
F677 ADL Care Provided for Dependent Residents: The facility failed to provide showers for one resident out of four sampled residents, resulting in poor hygiene and incomplete shower documentation. Resident #1 had greasy hair and a general unkempt appearance.
Report Facts
Facility census: 39
Deficiency cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant (CNA) | Interviewed regarding shower schedules and procedures | |
| Licensed Practical Nurse (LPN) B | Interviewed regarding shower assignments and procedures | |
| Director of Nurses (DON) | Interviewed regarding shower schedules and resident complaints |
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 13
Date: Jan 23, 2025
Visit Reason
Annual inspection survey conducted to assess compliance with federal and state regulations for Hickory Manor nursing facility.
Findings
The facility was found deficient in multiple areas including failure to complete criminal background checks and nurse aide registry checks prior to employment, failure to implement accurate baseline care plans, comprehensive care plans, and professional standards of care. Additional deficiencies were noted in medication management, infection control, and tuberculosis screening of employees.
Deficiencies (13)
F607: The facility failed to complete criminal background checks and nurse aide registry checks for seven of ten sampled staff prior to hire. Documentation was missing for multiple employees.
F655: The facility failed to implement an accurate baseline care plan for one resident upon admission, missing minimum healthcare information.
F655: The facility failed to implement a comprehensive care plan with specific interventions for four residents, including cultural competence and trauma-informed care.
F658: The facility failed to meet professional standards of care by not following physician orders for oxygen therapy and wound care for sampled residents.
F692: The facility failed to obtain a physician's order for a house supplement recommendation and failed to ensure nutritional assessments for four residents with significant weight loss.
F755: The facility failed to maintain a safe and effective medication system, including failure to reconcile narcotics and monitor psychotropic medication regimens.
F758: The facility failed to provide a PRN psychotropic medication policy and failed to ensure gradual dose reductions for residents using psychotropic drugs.
F880: The facility failed to establish and maintain an infection prevention and control program, including failure to implement enhanced barrier precautions for residents with wounds.
A4031: The facility failed to ensure tuberculosis screening tests were completed on hire for all staff, including failure to administer initial and annual tests timely.
A4061: The facility failed to conduct monthly pharmacist or registered nurse reviews of drug regimens for each resident, including documentation of irregularities.
A4075: The facility failed to provide personal attention and nursing care consistent with residents' conditions.
A4086: The facility failed to use acceptable infection control procedures and failed to report communicable diseases timely to the state department.
A8023: The facility failed to develop and implement written policies prohibiting abuse, neglect, and misappropriation of resident property, including failure to report as required.
Report Facts
Facility census: 37
Deficiencies cited: 13
Medication narcotics reconciliation missed: 39
Medication narcotics reconciliation missed: 80
Inspection Report
Life Safety
Census: 37
Capacity: 60
Deficiencies: 2
Date: Jan 23, 2025
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety regulations and maintenance of sprinkler and smoke barrier systems.
Findings
The facility failed to maintain the sprinkler system free of corrosion and foreign materials and did not maintain smoke barriers to resist the passage of smoke. These deficiencies had the potential to affect all occupants of the building.
Deficiencies (2)
K353: The facility failed to maintain the sprinkler system in accordance with NFPA 25 by not ensuring sprinklers were clean and free of corrosion and foreign material. Observations showed sprinkler heads loaded with dust and debris.
K372: The facility failed to maintain smoke barriers to resist the passage of smoke in accordance with NFPA 101. Observations showed holes filled with non-fire rated spray foam between the laundry and storage rooms.
Report Facts
Facility capacity: 60
Census: 37
Number of sprinkler heads loaded with dust and debris: 3
Size of holes in smoke barrier: 6
Size of hole in smoke wall: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judi Schmidt | Administrator | Signed the inspection report and plan of correction |
| Maintenance Supervisor | Interviewed regarding sprinkler inspection and smoke barrier repairs | |
| Maintenance Director | Responsible for monitoring compliance with sprinkler and smoke barrier corrective actions |
Inspection Report
Routine
Census: 37
Deficiencies: 8
Date: Jan 23, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including staff background checks, resident care planning, medication administration, infection control, and pharmaceutical services.
Findings
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.
Deficiencies (8)
Failed to complete Criminal Background Checks and Nurse Aide Registry checks for multiple staff prior to hire.
Failed to implement an accurate baseline care plan with specific interventions for a resident's immediate needs.
Failed to implement comprehensive care plans with specific interventions for multiple residents' individual needs including weight loss, wounds, pain, and anticoagulant use.
Failed to follow physician orders for oxygen therapy and wound care for multiple residents.
Failed to obtain physician orders for house supplements and failed to ensure dietitian completed nutritional assessments for residents with significant weight loss.
Failed to reconcile narcotics at each shift change for two medication carts.
Failed to limit PRN psychotropic medication orders to 14 days and failed to attempt gradual dose reductions for psychotropic medications for multiple residents.
Failed to implement Enhanced Barrier Precautions during wound care for residents, including failure to post signage, use gowns, and perform proper hand hygiene.
Report Facts
Facility census: 37
Weight loss percentage: 11.62
Weight loss percentage: 10.42
Narcotic reconciliation missed counts: 80
Narcotic reconciliation missed counts: 39
Narcotic reconciliation missed counts: 22
Narcotic reconciliation missed counts: 18
Narcotic reconciliation missed counts: 80
Narcotic reconciliation missed counts: 24
Narcotic reconciliation missed counts: 11
Narcotic reconciliation missed counts: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in wound care deficiency for failure to use isolation gown and improper application of wound medication |
| RN L | Registered Nurse | Named in wound care deficiency for failure to remove gown and gloves and perform hand hygiene properly |
| Administrator | Interviewed regarding background checks, care plans, medication and infection control deficiencies | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding care plans, medication regimen, wound care, and infection control deficiencies |
| Dietary Manager | Dietary Manager | Interviewed regarding dietitian visits and nutritional assessments |
| Registered Dietitian | Registered Dietitian (RD) | Interviewed regarding nutritional assessments and recommendations |
Inspection Report
Plan of Correction
Census: 36
Deficiencies: 1
Date: Sep 24, 2024
Visit Reason
The inspection was conducted to evaluate compliance with comprehensive care plan requirements for residents, specifically assessing the development and implementation of person-centered care plans.
Findings
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 of five sampled residents. The care plans lacked measurable objectives and were behind schedule due to transition to electronic medical records.
Deficiencies (1)
F 656: The facility failed to develop and implement comprehensive person-centered care plans within seven days after assessment and 21 days after admission for two residents. Care plans lacked measurable objectives and were delayed due to transition to electronic medical records.
Report Facts
Facility census: 36
Sampled residents: 5
Residents with deficient care plans: 2
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 1
Date: Sep 24, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to develop and implement comprehensive care plans within required timeframes for residents.
Complaint Details
Complaint #MO241812. The complaint involved failure to develop and implement care plans timely for residents, substantiated by interviews and record reviews.
Findings
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).
Deficiencies (1)
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.
Report Facts
Residents affected: 2
Facility census: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Interviewed regarding care plan requirements and delays due to EMR transition | |
| Licensed Practical Nurse (LPN) | MDS and care plan coordinator, interviewed about care plan delays and EMR implementation | |
| Administrator | Interviewed about care plan delays due to EMR transition |
Inspection Report
Plan of Correction
Census: 39
Deficiencies: 2
Date: Jun 4, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, specifically focusing on comprehensive care plans and medication administration at Hickory Manor.
Findings
The facility failed to meet professional standards for comprehensive care plans and medication administration, with deficiencies noted in physician order follow-through, documentation, and skin/wound care protocols for multiple residents.
Deficiencies (2)
F658: The facility failed to follow physician orders for four of five sampled residents, including incomplete documentation of skin assessments, medication administration, and wound care treatments.
A4055: The facility did not maintain a safe and effective medication system, as evidenced by deficiencies referenced in F658.
Report Facts
Facility census: 39
Missed opportunities for skin assessments: 32
Missed opportunities for medication administration: 10
Missed opportunities for weekly skin assessments: 7
Missed opportunities for oxygen tubing change: 2
Missed opportunities for distilled water change: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judi Schmitt | Administrator | Signed the statement of deficiencies and plan of correction |
| LPN A | Licensed Practical Nurse | Provided care to Resident #3 and described wound care procedures |
| Interim DON | Director of Nursing | Interviewed regarding expectations for order follow-through and documentation |
| NP | Nurse Practitioner | Rounded with Resident #3 and provided wound care |
| Administrator | Administrator | Interviewed on 06/04/24 regarding wound care and physician orders for Resident #3 |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 4
Date: Jun 4, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to follow physician's orders for four out of five sampled residents.
Complaint Details
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.
Findings
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.
Deficiencies (4)
Failure to follow physician's orders for Medihoney and bordered foam application and weekly skin assessments for Resident #1.
Failure to follow orders for Triad ointment, UAD flush, and weekly skin assessments for Resident #2.
Failure to administer Lanolin ointment, weekly weights, pressure ulcer risk assessments, and Vitamin D supplementation as ordered for Resident #3.
Failure to administer Toprol XL medication and to change oxygen tubing and distilled water as ordered for Resident #5.
Report Facts
Residents affected: 4
Missed medication/treatment opportunities: 32
Missed medication/treatment opportunities: 10
Missed medication/treatment opportunities: 7
Missed medication/treatment opportunities: 4
Missed medication/treatment opportunities: 3
Missed medication/treatment opportunities: 4
Missed medication/treatment opportunities: 2
Missed medication/treatment opportunities: 1
Missed medication/treatment opportunities: 2
Missed medication/treatment opportunities: 2
Resident census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Provided wound care to Resident #3 and described wound care procedures | |
| Nurse Practitioner (NP) | Rounded with Resident #3 and provided wound care orders | |
| Interim Director of Nursing (DON) | Interviewed and stated expectations for following orders and documentation | |
| Administrator | Interviewed and stated expectations for following physician orders and chart audits |
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 11
Date: Jan 11, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including resident assessments, care plans, medication management, safety, staffing, and vaccination protocols.
Findings
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.
Deficiencies (11)
Failed to document complete and accurate Minimum Data Set (MDS) assessments for residents.
Failed to implement individualized care plans with specific interventions for residents receiving psychotropic medications.
Failed to obtain physician orders and complete safety evaluations for use of trapeze for a resident.
Failed to follow physician orders for catheter changes, hearing aid battery changes, and oxygen tubing changes.
Failed to assess residents for bed rail use and obtain informed consent prior to installation.
Failed to post nurse staffing information in a clear and accessible manner daily.
Failed to ensure pharmacist medication regimen reviews included appropriate diagnoses and monitoring for antipsychotic medications and limited PRN psychotropic medication use to 14 days or documented rationale for extension.
Failed to maintain dumpster lids closed to prevent pests and contain garbage.
Failed to provide and document education, offer, and consent/refusal for pneumococcal and influenza vaccinations for residents.
Failed to provide and document education, offer, and consent/refusal for COVID-19 vaccinations for residents.
Failed to provide required annual nurse aide training including dementia care and abuse prevention for sampled CNAs.
Report Facts
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 35
Residents affected: 3
Residents affected: 4
Residents affected: 4
CNAs affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided interviews regarding MDS assessments, care plans, trapeze use, bed rails, medication management, vaccinations, and nurse aide training |
| Administrator | Administrator | Provided interviews regarding MDS assessments, trapeze use, bed rails, nurse staffing posting, vaccinations, and nurse aide training |
| Registered Nurse H | Registered Nurse | Interviewed regarding Foley catheter and hearing aid battery changes |
| Certified Medication Technician B | Certified Medication Technician | Interviewed regarding PRN haloperidol use |
| Pharmacist | Pharmacist | Interviewed regarding medication regimen reviews and expectations for appropriate diagnoses and PRN medication orders |
| Dietary Manager | Dietary Manager | Interviewed regarding dumpster use and lid closure |
| Dietary Aide G | Dietary Aide | Interviewed regarding dumpster use and lid closure |
| Maintenance Director | Maintenance Director | Interviewed regarding dumpster lid closure |
| CNA A | Certified Nurse Aide | Interviewed regarding training system and dementia/abuse training |
Inspection Report
Life Safety
Census: 35
Deficiencies: 4
Date: Jan 11, 2024
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to maintain smoke barriers to resist the passage of smoke and did not maintain their emergency generator to meet NFPA standards for power transfer time. These deficiencies potentially affect all residents of the facility.
Deficiencies (4)
K372 Subdivision of Building Spaces - Smoke Barrier Construction. The facility failed to maintain smoke barriers to resist the passage of smoke, with unsealed penetrations in smoke walls on the 100 and 300 halls.
K918 Electrical Systems - Essential Electric System Maintenance and Testing. The facility failed to maintain their generator according to NFPA standards, with power transfer occurring after 14 seconds instead of the required 10 seconds.
A1086 19 CSR 30-85.012(79) LSC Edition Required per Date of Fac Plan. The facility did not meet the 1997 edition of the Life Safety Code as referenced in K918.
A2054 19 CSR 30-85.022(29) Smoke Section Walls/Doors. The facility did not meet smoke section wall requirements as referenced in K372.
Report Facts
Facility census: 35
Power transfer time: 14
Penetrations in smoke barriers: 6
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 1
Date: Oct 30, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to notify a resident's responsible party after the resident sustained injuries from two separate falls, one requiring emergency room evaluation.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to notify resident's responsible party of falls and emergency room transfer as required by facility policy.
Report Facts
Facility census: 32
Notification attempts: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN) | Interviewed regarding notification procedures and failures |
| Registered Nurse B | Registered Nurse (RN) | Interviewed about notification attempts and documentation |
| Director of Nursing | Director of Nursing (DON) | Interviewed about fall incident, emergency room transfer, and notification failures |
| Administrative Assistant | Administrative Assistant | Interviewed jointly with DON about notification policies and procedures |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 2
Date: Oct 30, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to failure to notify a resident's responsible party after the resident sustained injuries from falls.
Complaint Details
Complaint #MO00226392 was investigated regarding failure to notify the responsible party of a resident's fall and injuries. The complaint was substantiated based on record review and staff interviews.
Findings
The facility failed to notify the responsible party of a resident's fall and injuries on multiple occasions, including failure to document notification attempts and timely communication with the resident's representative.
Deficiencies (2)
F580 Notification of Changes: The facility failed to notify the resident's responsible party after the resident sustained injuries from falls and was transferred to the emergency room. Staff did not document notification attempts or times of notification.
A4088 Notify Responsible Party-Change in Condition: Facility staff did not immediately notify the person designated in the resident's record as the responsible party after a significant change in the resident's condition, as evidenced by the failure described in F580.
Report Facts
Facility census: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in documentation and interview regarding notification failures and resident transfer to emergency room |
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse | Interviewed regarding notification procedures and failures |
| Registered Nurse (RN) B | Registered Nurse | Interviewed regarding notification attempts and failures |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 22, 2023
Visit Reason
The inspection was conducted as an annual survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 22, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with related federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Plan of Correction
Census: 37
Deficiencies: 2
Date: Nov 21, 2022
Visit Reason
The inspection was conducted to assess compliance with quality of care and medication administration regulations at Hickory Manor, following concerns about treatment and care of a resident with pneumonia and RSV.
Findings
The facility failed to ensure appropriate treatment and care for a resident diagnosed with pneumonia and RSV, including failure to notify the physician of new diagnoses and medication orders, and failure to administer ordered medications. Medication administration policies were not fully followed, resulting in missing medications in the emergency kit and incomplete documentation.
Deficiencies (2)
F684 Quality of care was not met as the facility failed to ensure a resident with pneumonia and RSV received appropriate treatment and care, including notifying the physician of new diagnoses and medication orders and administering ordered medications.
A4055 Safe and effective medication system was not met as the facility lacked required medications in the emergency kit and failed to ensure proper medication order transcription and administration.
Report Facts
Facility census: 37
Inspection Report
Routine
Census: 32
Deficiencies: 5
Date: Mar 3, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, food safety, infection control, and facility maintenance at Hickory Manor nursing home.
Findings
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.
Deficiencies (5)
Failure to provide timely showers and grooming assistance to residents as care planned.
Failure to prime insulin pen needle before administering rapid acting insulin to a resident.
Failure to maintain food safety standards including improper facial hair coverings and storing scoops in dry food bins.
Failure to complete and document tuberculosis screening tests for staff and residents as required.
Failure to maintain kitchen equipment and shelving units in a clean and sanitary manner, including areas of erosion and buildup of lint.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 32
Residents affected: 5
Residents affected: 3
Showers provided: 4
Showers provided: 3
Showers provided: 4
Showers provided: 2
Employee hire date: Oct 5, 2021
Employee hire date: Jan 11, 2022
Employee hire date: Oct 21, 2021
Employee hire date: Feb 4, 2022
Employee hire date: Oct 22, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in medication error finding for failing to prime insulin pen needle |
| RN D | Registered Nurse | Provided information on insulin administration and resident care |
| Director of Nursing | Director of Nursing (DON) | Provided information on resident care, insulin pen priming training, and TB testing responsibilities |
| Administrator | Facility Administrator | Provided information on insulin pen policy and TB testing expectations |
| DA F | Dietary Aide | Observed not wearing facial hair covering and discussed food safety practices |
| Dietary Manager | Dietary Manager | Provided information on food safety policies and kitchen cleaning |
| Maintenance Supervisor | Maintenance Supervisor | Provided information on kitchen maintenance and cleaning |
| CNA E | Certified Nursing Assistant | Provided information on resident shower and grooming assistance |
| CNA B | Certified Nursing Assistant | Provided information on resident shower and grooming assistance |
| MDS Coordinator | Minimum Data Set Coordinator | Provided information on resident care plans and shower needs |
Inspection Report
Annual Inspection
Census: 32
Deficiencies: 5
Date: Mar 3, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations for Hickory Manor nursing facility.
Findings
The facility was found deficient in multiple areas including assistance with activities of daily living, medication administration errors, food safety violations, infection control, and environmental conditions. The facility failed to ensure timely showers and grooming assistance for dependent residents, prevent significant medication errors, maintain food safety standards, and implement adequate infection prevention and control measures.
Deficiencies (5)
F677 ADL Care Provided for Dependent Residents: The facility failed to ensure staff provided timely showers and grooming assistance to dependent residents as planned.
F760 Residents are Free of Significant Med Errors: The facility failed to prevent a significant medication error when a nurse did not prime the insulin pen needle before administration.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to store and prepare food in accordance with professional food safety standards, including improper hair restraints and unsanitary kitchen conditions.
F880 Infection Prevention & Control: The facility failed to ensure staff completed required tuberculosis screening and monitoring for employees and residents.
F921 Safe/Functional/Sanitary/Comfortable Environment: The facility failed to maintain kitchen equipment and shelving units in a clean and sanitary manner, with evidence of erosion and buildup of contaminants.
Report Facts
Facility census: 32
Plan of correction completion dates: Most corrective actions completion date 4/15/2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse D | Director of Nursing | Provided statements regarding resident care and medication administration |
| Licensed Practical Nurse A | LPN | Involved in insulin administration error |
| Certified Nursing Assistant E | CNA | Provided observations on resident care and shower assistance |
| Dietary Aide F | Dietary Aide | Observed food safety violations in kitchen |
| Administrator | Administrator | Signed inspection report and plan of correction |
Inspection Report
Life Safety
Census: 32
Capacity: 60
Deficiencies: 3
Date: Mar 3, 2022
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and related fire safety regulations at Hickory Manor.
Findings
The facility failed to properly enclose hazardous areas such as the laundry room, did not conduct required sprinkler system inspections and maintenance, and failed to complete required monthly and four-hour load tests on the emergency generator. These deficiencies posed potential risks to residents, staff, and visitors in the event of a fire or power outage.
Deficiencies (3)
K321 Hazardous Areas - The facility failed to properly enclose the laundry room as a hazardous area by propping open the door and having an open conduit to an adjacent storage room. This deficient practice could affect all residents, staff, and visitors in a fire event.
K353 Sprinkler System - The facility failed to conduct a required quarterly inspection and a five-year internal-pipe inspection of the sprinkler system, risking fire safety for all occupants.
K918 Electrical Systems - The facility failed to complete monthly load tests and a required four-hour load test on the emergency generator in the past three years, risking generator failure during power outages.
Report Facts
Facility capacity: 60
Census: 32
Years since last internal pipe inspection: 12
Times generator exercised weekly: 1
Times generator exercised annually: 12
Times generator exercised every 36 months: 1
Inspection Report
Plan of Correction
Census: 23
Deficiencies: 2
Date: Mar 3, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted along with a review of pain management practices following concerns about pain medication availability for a resident.
Findings
The facility failed to ensure pain medication was available when needed for one resident, and pain assessments were not consistently completed. Staff did not document pain assessments or respond adequately to the resident's requests for pain medication.
Deficiencies (2)
F697 Pain Management: The facility failed to assess, monitor, and treat pain and ensure pain medication was available when needed for one resident. Pain assessments were not completed as ordered and staff did not respond to the resident's requests for pain medication.
A4074 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the pain management deficiencies noted in F697.
Report Facts
Facility census: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jami Allen | Administrator | Signed the inspection report and plan of correction |
Inspection Report
Routine
Deficiencies: 0
Date: Dec 17, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 25, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 14, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Routine
Deficiencies: 0
Date: May 22, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Annual Inspection
Census: 34
Deficiencies: 9
Date: Jun 20, 2019
Visit Reason
Annual inspection survey conducted to assess compliance with federal and state regulations for Hickory Manor nursing facility.
Findings
The facility was found deficient in multiple areas including comprehensive care planning, documentation of residents' code status, safe use of gait belts, medication error rates, infection control, food safety, and bed rail safety checks. Several residents' care plans and medical records lacked required documentation and staff failed to consistently follow policies and procedures.
Deficiencies (9)
F656 Comprehensive Care Plan: The facility failed to develop a comprehensive person-centered care plan for Resident #15, specifically regarding an indwelling urinary catheter.
F678 Cardio-Pulmonary Resuscitation (CPR): The facility failed to ensure staff consistently documented residents' code status for Residents #2, #16, and #34.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure safety of Residents #4, #14, and #24 during transfers and failed to lock wheelchairs.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to ensure appropriate catheter care and monitoring for Residents #17, #31, and #34.
F759 Safe/Effective Medication System: The facility failed to ensure safe insulin pen priming and administration for Resident #24, resulting in medication errors.
F760 Residents are Free of Significant Med Errors: The facility failed to ensure Resident #24 was free from significant medication errors during a random medication pass observation.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to protect food from contamination, including improper hand hygiene and coughing into food.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention and control program to prevent communicable diseases.
F909 Resident Bed: The facility failed to complete bed rail safety checks and ensure proper maintenance and documentation for Residents #22 and #31.
Report Facts
Facility census: 34
Medication error rate: 6.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) A | Registered Nurse | Involved in medication administration and insulin pen priming errors |
| Certified Nurse Aide (CNA) G | Certified Nurse Aide | Observed assisting resident with transfers and gait belt use |
| Therapy Director | Therapy Director | Provided information about wheelchair and gait belt use |
| Administrator | Facility Administrator | Provided information on infection control and code status procedures |
| Social Service Director (SSD) | Social Service Director | Discussed residents' code status documentation |
| Licensed Practical Nurse (LPN) B | Licensed Practical Nurse | Discussed physician notification for DNR orders |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jun 20, 2019
Visit Reason
The inspection was conducted as an annual recertification survey focusing on life safety code compliance and licensure inspection.
Findings
No Emergency Preparedness deficiencies were cited. No state licensure deficiencies were found during the inspection.
Inspection Report
Follow-Up
Census: 34
Deficiencies: 10
Date: Mar 18, 2019
Visit Reason
This follow-up inspection was conducted to verify correction of previously cited deficiencies related to resident care, medication administration, infection control, and safety measures at Hickory Manor.
Findings
The facility was found to have multiple deficiencies including failure to ensure comprehensive person-centered care plans, medication errors, unsafe resident handling, infection control lapses, and incomplete documentation of residents' code status and bed rail safety checks.
Deficiencies (10)
F 623 Notice Requirements Before Transfer/Discharge: The facility failed to issue written discharge notices per Federal and State regulations and guidelines.
F 656 Person-Centered Care Plan: The facility failed to ensure staff developed a comprehensive care plan for a resident with an indwelling urinary catheter.
F 678 Cardio-Pulmonary Resuscitation (CPR): The facility failed to consistently document residents' code status information in medical records and care plans for three residents.
F 689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure the safety of three residents during transfers and failed to lock wheelchairs, resulting in unsafe transfers.
F 690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to ensure physician orders were complete and staff monitored catheter care according to standards for three residents.
F 759 Free of Medication Error Rates 5 Percent or More: The facility failed to ensure medication error rates were less than 5%, with two errors affecting one resident.
F 760 Residents Free of Significant Medication Errors: The facility failed to ensure residents were free of significant medication errors during a random medication pass observation.
F 812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to protect food from contamination when staff touched food with bare hands and coughed over a food tray.
F 880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention program including hand hygiene, isolation precautions, and tuberculosis testing.
F 909 Resident Bed: The facility failed to complete bed rail safety checks and document restraint side rail assessments for two residents.
Report Facts
Facility census: 34
Sample size for review: 20
Medication error rate: 6.4
Medication error opportunities: 31
Inspection Report
Plan of Correction
Census: 32
Deficiencies: 3
Date: Apr 26, 2018
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident transfer/discharge notices, incontinence care, and infection prevention and control at Hickory Manor.
Findings
The facility failed to notify residents and their representatives in writing about transfers or discharges to hospitals, failed to ensure proper incontinence care and catheter management, and did not maintain adequate infection control procedures, including hand hygiene and catheter care.
Deficiencies (3)
F623 Notice Requirements Before Transfer/Discharge: The facility failed to notify residents and their representatives in writing of transfers or discharges to hospitals and failed to provide the Ombudsman with copies of such notices for three residents.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to ensure staff performed proper incontinence care and catheter management for residents, leading to potential urinary tract infections.
F880 Infection Prevention & Control: The facility failed to use appropriate infection control procedures, including hand hygiene and catheter care, resulting in risk of infection transmission among residents.
Report Facts
Facility census: 32
Sample size: 13
Residents involved: 3
Residents involved: 5
Inspection Report
Life Safety
Census: 32
Capacity: 60
Deficiencies: 4
Date: Apr 26, 2018
Visit Reason
The inspection was conducted to evaluate compliance with fire safety and emergency preparedness requirements, including fire alarm system testing, sprinkler system maintenance, fire drills, and emergency plan testing.
Findings
The facility failed to conduct required emergency plan tabletop exercises, semi-annual fire alarm inspections, annual fire sprinkler inspections, and quarterly fire drills on all shifts. These deficiencies had the potential to affect all residents, staff, and visitors by causing delays or failures in emergency response.
Deficiencies (4)
E039: The facility failed to conduct a required tabletop exercise covering hazards in the emergency plan. The administrator was unaware of this requirement.
K345: The facility failed to conduct a semi-annual fire alarm inspection and maintain required documentation. The maintenance supervisor was unaware of this requirement.
K353: The facility failed to conduct an annual fire sprinkler inspection and the required five-year internal inspection. Documentation was not provided.
K712: The facility failed to conduct quarterly fire drills on all shifts at varying times. Some drills were missed or conducted too closely together.
Report Facts
Facility census: 32
Facility capacity: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Rogers | Administrator | Named in relation to emergency plan and fire safety deficiencies |
| Maintenance Supervisor | Interviewed regarding fire alarm and sprinkler system inspection requirements |
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