Hickory Creek At Columbus

Based on observation and interview, the facility failed to ensure foods were stored in a sanitary manner related to unlabeled foods for 1 of 3 kitchen observations.Findings include:During the initial tour of the facility kitchen with [NAME] 5 on 09/08/2025 at 7:46 A.M., the following items were observed in the refrigerator:-A tray that contained two cups of ambrosia salad, a small bowl of potato salad, and a ham sandwich in plastic bag. The items nor the tray were labeled with a prepared on or use by date,-A tray that contained four small cups of a fruit crumble dessert, a small cup of cucumber tomato salad, and a small cup of tapioca pudding. The items nor the tray were labeled with a prepared on or use by date, -A large, unlabeled pitcher that was less than half full of an orange drink, and -A large, unlabeled pitcher that was less than half full of a pink drink.During an interview, on 09/08/2025 at 7:48 A.M., [NAME] 5 indicated the items on trays were from the weekend and should have been labeled with prepared on date. The drink pitchers should have been labeled with a prepared on date. All items not labeled were removed and disposed. The current facility policy, titled Food Storage, most recently revised on 05/25, was provided by the Administrator on 09/12/2025 at 10:46 A.M. The policy indicated, .Leftover prepared foods.The food must clearly be labeled with the name of the product, the date it was prepared, and marked to indicate the date by which the food shall be consumed or discarded.3.1-21(i)(2)3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure care planned interventions were implemented for 2 of 12 residents reviewed for Care Plans. (Residents 19 and 7)Findings include:1. Resident 19's room was observed on 09/10/2025 at 1:35 P.M. The resident's call light was observed near her bed. The call light was white, and there was no bright colored tape attached to the call light.The resident was observed on 09/11/2025 at 9:07 A.M. The resident was in her room in bed. The resident's call light was within reach. There was no brightly colored tape attached to the call light. The resident's clinical record was reviewed on 09/10/2025 at 2:27 P.M. An Annual Minimum Data Set (MDS) assessment, dated 07/02/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, hypertension, and seizure disorder. The resident used a wheelchair and was dependent on staff for mobility. The resident experienced one fall without injury and one fall with an injury that was not major since the last assessment. The resident's Fall Care Plan, with a start date of 08/04/2023, included the following interventions:- A current intervention, with a start date of 11/04/2024, that indicated the resident was to have brightly colored tape on her call light.During an interview, on 09/11/2025 at 1:53 PM, Certified Nurse Aide (CNA) 3 indicated staff used pocket sheets that reflected the resident's current interventions. CNA 3 reviewed the current pocket sheet, dated 09/11/2025. The pocket sheet indicated there should be brightly colored tape on the resident's call light. The resident's room was observed with CNA 3 on 09/11/2025 at 1:59 P.M. The resident's call light was observed in an open drawer near the bed. There was no brightly colored tape on the call light. 2. Resident 7 was observed on 09/08/2025 at 9:44 A.M. The resident was in her room in a high-backed wheelchair next to her bed. The resident's call light was attached to the wall but was not visible or within reach of the resident. The resident indicated she could not call for assistance because she didn't have a call light within reach.The resident was observed on 09/10/2025 at 9:30 A.M. The resident was in her room in a high-backed wheelchair. The resident's overbed table was in front of her and she was holding a washcloth in each hand. The resident indicated she needed assistance, but she didn't have her call light. A soft touch call light was observed in the top drawer of the resident's nightstand behind the resident's wheelchair. The resident indicated she was capable of using the soft touch call light. CNA 4 entered the resident's room and was asked about the call light. CNA 4 indicated the resident didn't use the call light, but she would go ahead and place the call light in the resident's lap. She then assisted the resident with putting her eyeglasses on, placed and then repositioned the resident's neck pillow, and began looking for the resident's peppermint candies at the resident's request. The resident's record was reviewed on 09/12/2025 at 2:00 P.M. A Quarterly MDS assessment, dated 08/18/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, Parkinson's disease, anxiety, and depression. The resident did not have a limited range of motion of her upper or lower extremities. The resident did use a wheelchair and was dependent on staff for most activities of daily living.A Behavior Care Plan, with a start date of 09/11/2023 and a revision date of 08/14/2025, indicated the resident used her call light excessively. The goal was for the resident to use her call light to notify staff that she was requesting help as needed, and included the following intervention:- A current intervention, with a start date of 09/11/2023, to ensure the call light was within the resident's reach when she was in her room.During an interview, on 09/12/2025 at 10:30 A.M., the Director of Nursing indicated the facility did not have a policy for following care plans.During an interview, on 09/12/2025 at 2:01 P.M., the Administrator indicated the facility did not have a policy for call lights related to call light usage. Call lights should be available for residents' use.3.1-35(g)(2)

Based on record review and interview, the facility failed to provide physician prescribed medications in a timely manner for 2 of 6 residents reviewed for medications. (Residents 6 and 29) Findings include:1.The clinical record for Resident 6 was reviewed on 09/11/2025 at 10:24 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 07/16/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disease, anxiety, and depression.
The Electronic Medication Administration Record (EMAR) indicated the resident was to receive the medication Paxlovid 100/150 milligrams (mg), twice a day, once from 7:00 A.M. to 11:00 A.M., and once from 5:00 P.M. to 10:00 P.M., for a diagnosis of COVID-19, with a start date of 08/31/2025, and a discontinued date of 09/04/2025. The record indicated the medication was not administered due to being unavailable on the following dates and times:
-08/31/2025 at 7:00 A.M. to 11:00 A.M.,
-08/31/2025 at 5:00 P.M. to 10:00 P.M.,
-09/01/2025 at 7:00 A.M. to 11:00 A.M.,
-09/01/2025 at 5:00 P.M. to 10:00 P.M., and
-09/02/2025 at 7:00 A.M. to 11:00 A.M.
The Progress Notes from 08/30/2025 through 09/08/2025, were provided by the Administrator on 09/12/2025 at 10:49 A.M., and included, but were not limited to, the following:
-A note, dated 08/30/2025 at 7:18 P.M., indicated the resident was symptomatic, had tested positive for COVID-19, had a deep unproductive cough, and was in droplet isolation. New orders received from Telehealth indicated the resident was to receive Paxlovid 150/100 mg, by mouth, twice a day, for five days.
The clinical record lacked documentation the physician or the pharmacy was notified of the medication not being available.
2. The clinical record for Resident 29 was reviewed on 09/11/2025 at 10:12 A.M. A Quarterly MDS assessment, dated 08/06/2025, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, heart failure, diabetes, and dementia.
The EMAR indicated the resident was to receive the medication Paxlovid 150/100 mg, twice a day, once from 7:00 A.M. to 11:00 A.M., and once from 5:00 P.M. to 10:00 P.M., for a diagnosis of COVID-19, with a start date of 08/31/2025, and a discontinued date of 09/04/2025. The record indicated the medication was not administered due to being unavailable on the following dates and times:
- 08/31/2025 at 7:00 A.M. to 11:00 A.M.,- 08/31/2025 at 5:00 P.M. to 10:00 P.M.,- 09/01/2025 at 7:00 A.M. to 11:00 A.M.,- 09/01/2025 at 5:00 P.M. to 10:00 P.M., and- 09/02/2025 at 7:00 A.M. to 11:00 A.M.
The Progress Notes from 08/30/2025 through 09/08/2025, were provided by the Administrator on 09/12/2025 at 10:49 A.M., and lacked documentation the physician or the pharmacy was notified of the medication not being available.
During an interview, on 09/12/2025 at 10:04 A.M., Licensed Practical Nurse 2 indicated the physician's orders for medications were sent to the pharmacy. It usually took less than 24 hours to receive medications. If a nurse needed to administer a medication and it was not available in the facility, they could contact the pharmacy to get the medication STAT ordered. With a STAT order, there was usually a four-hour turn around. They could also get the medication from the local pharmacy, someone from the facility could go pick it up or have the medication delivered.
During an interview with the Infection Preventionist (IP) and the Director of Nursing (DON), on 09/12/2025 at 10:12 A.M., the IP indicated it was a long weekend when the medication was ordered. The DON indicated typically, instead of just documenting a medication as unavailable nursing staff should document if they reached out to the pharmacy and notified the physician. If they put a notation in the resident's record, nursing staff would know what was going on.
The current Medication Shortages/Unavailable Medications policy, with a revised date of 08/01/2024, was provided by the Administrator on 09/12/2025 at 10:49 A.M. The policy indicated, .If the medication shortage is discovered at the time of medication administration, Facility staff should immediately notify the Pharmacy.If the medication is not available in the Emergency Medication Supply, Facility staff should notify Pharmacy and arrange for a STAT (immediate) delivery.If the ordered medication is not available in the Emergency Medication Supply, the licensed Facility nurse should call Pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action.
3.1-25(a)

Based on record review and interview, the facility failed to monitor a resident's blood pressure as ordered by the physician's for 1 of 14 residents reviewed for quality of care. (Resident 7)
Findings include:
The clinical record for Resident 7 was reviewed on 08/27/24. A Quarterly MDS (Minimum Data Set) assessment, dated 08/05/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, diabetes, depression, and insomnia.
A current physician's order, with a start date of 06/13/24, indicated the staff were to obtain the resident's blood pressure daily and to notify the physician's office if the systolic (top number) was less than 100. The blood pressure record was to be taken to the next appointment on 12/13/24.
The June, July, and August 2024, EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) lacked any documented blood pressures.
The Vitals Report for June, July, and August 2024, lacked documented blood pressures for Resident 7 on the following dates: 06/15/24, 06/16/24, 06/18/24, 06/20/24, 06/21/24, 06/24/24, 06/25/24, 06/29/24, 06/30/24, 07/27/24, 07/28/24, 07/31/24, 08/01/24, 08/02/24, 08/05/24, 08/06/24, 08/10/24, 08/11/24, 08/15/24, 08/16/24, 08/19/24, 08/20/24, and 08/22/24.
During an interview on 08/29/24 at 11:05 A.M., LPN (Licensed Practical Nurse) 2 indicated when a resident had an order to monitor their blood pressure it would be documented on the EMAR/ETAR.
During an interview on 08/29/24 at 11:08 A.M., the DON (Director of Nursing) indicated the resident's blood pressure should have been monitored daily per the physician's order.
The current facility policy titled, Documenting Guidelines for Nursing with a revision date of 7/24, was provided by the DON on 08/29/24 at 2:45 P.M. The policy indicated, .To accurately document in an organized manner all information related to the resident in the medical record .
3.1-37(a)

Based on record review and interview, the facility failed to notify the physician of blood glucose levels per the physician's order for 1 of 14 residents reviewed for notification of change. (Resident 8)
Findings include:
The clinical record for Resident 8 was reviewed on 08/28/24 at 2:25 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 08/21/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, heart failure, hypertension, diabetes, anxiety, and depression.
A current physician's order, with a start date of 03/20/24, indicated the resident was to be administered insulin lispro per a sliding scale. The physician was to be notified if the resident's blood glucose level was greater than 350.
The June, July, and August 2024, EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) indicated the resident's blood glucose levels were greater than 350 on the following dates and times:
- On 06/10/24 at 11:00 A.M., the resident's blood glucose level was 368,
- On 06/20/24 at 11:00 A.M., the resident's blood glucose level was 355,
- On 06/25/24 at 11:00 A.M., the resident's blood glucose level was 367,
- On 07/08/24 at 11:00 A.M., the resident's blood glucose level was 399,
- On 07/21/24 at 11:00 A.M., the resident's blood glucose level was 389,
- On 08/19/24 at 7:00 A.M., the resident's blood glucose level was 358, and
- On 08/19/24 at 11:00 A.M., the resident's blood glucose level was 394.
The resident's clinical record lacked any documentation the physician was notified of the blood glucose levels.
During an interview on 08/29/24 at 2:09 P.M., LPN (Licensed Practical Nurse) 2 indicated the resident's blood glucose levels were documented on the EMAR/ETAR. If the blood glucose was out of the parameter and if the nurse was required to call the physician it would be documented on the EMAR/ETAR and in a progress note. They would document if there were any new orders in a progress note.
During an interview on 08/29/24 at 2:55 P.M., the DON (Director of Nursing) indicated the resident did not suffer any ill effects related to the physician not being notified of the blood glucose levels.
The current facility policy titled, Blood Glucose Monitoring, with a revision date of 2/2015, was provided by the DON on 08/29/24 at 2:45 P.M. The policy indicated, .The physician will be notified when the resident's blood glucose is outside the physician stated parameters .
3.1-5(a)(2)

Based on interview and record review, the facility failed to ensure a resident's record accurately reflected the administration of a narcotic medication for 1 of 3 residents reviewed for resident records. (Resident B)
Findings include:
The clinical record for Resident B was reviewed on 01/12/24 at 2:17 p.m. An admission MDS (Minimum Data Set) assessment, dated 12/02/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, prostate cancer and Chronic Obstructive Pulmonary Disease.
The November 2023 EMAR (electronic medication administration record) indicated the resident could receive oxycodone/acetaminophen (a narcotic pain medication) 5 mg (milligrams), 325 mg every four hours PRN (as needed) for pain.
During an interview on 01/12/23 at 2:13 P.M., Resident B indicated on Sunday 11/26/23 RN 2 asked him after lunch to take his PRN pain medication. He told her he was not having any pain and didn't need the medication. She told him if he didn't take it she would have to throw it away.
The Controlled Substance Record indicated the resident received oxycodone/acetaminophen 5 mg, 325 mg on 11/26/23 at 7:15 A.M. and 1:00 P.M.
Review of the November 2023 EMAR lacked documentation of the administration of the oxycodone/acetaminophen 5 mg, 325 mg on 11/26/23 at 7:15 A.M. and 1:00 P.M.
During an interview on 01/16/24 at 2:01 P.M., RN 3 indicated a PRN medication should not be removed from the medication cart until the resident makes the request for the medication. Blanks in the EMAR indicated the medication was not given. When a controlled substance needed to be destroyed, there should be two nurses, the medication was placed in the drug buster container and both nurses sign the controlled substance record sheet.
The current facility pharmacy policy with a revision dated of 01/10/22, was provided by the Director of nursing on 01/16/24 at 3:00 P.M. The policy indicated, .Document the administration of controlled substances in accordance with Applicable Law .Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN medications, application sight) on appropriate forms .Medication administration will be recorded on the MAR (Medication Administration Record)/EMAR or TAR (Treatment Administration Record) after given .
This citation relates to Complaint IN00422886.
3.1-50(a)(1)
3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to store medications appropriately related to insulin pens for 1 of 2 medication carts reviewed. (Back Hall medication cart)
Findings include:
On 06/12/23 at 10:55 A.M., the Back Hall medication cart was observed with RN 2, and contained the following:
- A Lispro insulin pen for Resident 5, with an open date of 05/14/23. The nurse verified the open date. The pen was 1/4 full. The resident had received the insulin that morning.
- A Lispro insulin pen for Resident 7, with an open date of 05/14/23. The nurse verified the open date. The pen was 1/4 full. The resident had received the insulin that morning.
During an interview on 5/14/23 at 10:58 A.M., RN 2 indicated the Lispro insulin pens were good for 30 days after the open date.
During an interview on 06/12/23 at 2:00 P.M., the Administrator indicated the facility did not have a specific medication storage policy, they followed the pharmacy recommendations.
The current facility pharmacy manual, with a revised date of 01/01/22, was provided by the DON on 06/12/23 at 11:45 A.M. The manual indicated, .Insulin Lispro pen once opened is good for 28 days . The pens should have been taken out of use after 06/10/23.
3.1-25(j)
3.1-25(o)

Based on interview and record review, the facility failed to identify pressure ulcers in a timely manner and document treatment administrations for 1 of 2 residents reviewed for pressure ulcers. (Resident 1)
Findings include:
During an interview on 06/07/23 at 9:31 A.M., Resident 1 indicated she had pressure wounds on her bottom that had recently healed.
The resident's record was reviewed on 06/11/23 at 4:51 P.M. A Significant Change MDS (Minimum Data Set) assessment, dated 05/19/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, diabetes, heart failure, renal disease, and hypertension. The resident required extensive staff assistance with transferring, toileting, and personal hygiene. The resident was at risk for pressure ulcers, and currently had one Unstageable pressure ulcer (obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough [moist, non-viable tissue] or eschar [dead tissue]).
A Wound Management Detail Report, dated 05/10/23, indicated a pressure ulcer was identified on the resident's left buttock that measured 1.3 cm (centimeters) x (by) 0.6 cm. The wound was unstageable, as it was 100% (percent) covered by slough.
A Progress Note, dated 05/10/23 at 3:02 P.M., indicated a new, unstageable pressure ulcer was identified on the resident's left buttock. A new physician's order was obtained for treatment. The treatment was the daily application of Santyl (a medication that removed dead tissue from wounds) and an Optifoam dressing (a waterproof foam dressing with a high fluid-handling capacity).
A Wound Management Detail Report, dated 05/26/23, indicated the pressure ulcer on the resident's left buttock measured 1 cm x 1 cm. The wound was still unstageable, as it was 100% covered by slough.
A Wound Management Detail Report, dated 05/26/23, indicated a new pressure ulcer was identified on the resident's right buttock that measured 1.6 cm x 2 cm. This wound was unstageable, as it was 100% covered by slough.
A Progress Note, dated 05/26/23, indicated a new, unstageable pressure ulcer was identified on the resident's right buttock. New interventions included a new wound treatment order, a low air loss mattress, and new physician's orders for a multivitamin and zinc supplements. The progress note indicated the current treatment order for the right buttock wound was Medihoney (a honey wound gel) and an Optifoam dressing.
The May 2023 ETAR (Electronic Treatment Administration Record) was provided by the DON (Director of Nursing) on 06/12/23 at 1:03 P.M. The record indicated the following physician ordered treatments were administered:
- The Santyl and Optifoam dressing treatment was administered daily to the left buttock from 05/10/23 until it was discontinued on 05/26.23, and
- The Medihoney and Optifoam dressing treatment was administered daily to the left buttock from 05/26/23 until it was discontinued on 05/30/23.
- A treatment listed on the May 2023 ETAR indicated nursing staff were to apply Skin Prep (a liquid, film forming dressing) to the dry area on the right buttock every shift from 05/10/23 until the treatment was discontinued on 05/30/23.
The record lacked documentation of any other treatment to the wound on the resident's right buttock.
Both wounds were documented as resolved on 05/30/23 in the Wound Management Detail Report.
During an interview on 06/12/23 at 11:25 A.M., the DON indicated the wounds on the resident's buttocks should have been identified before they were unstageable wounds. The wound on the resident's right buttock was identified one day and gone a few days later.
During an interview on 06/12/23 at 2:35 P.M., CNA (Certified Nurse Aide) 3 indicated staff were to look out for skin impairments. They would observe the residents' skin while assisting a resident with toileting, bathing, dressing, and undressing. If they found a wound, they would notify the nurse. They also filled out shower sheets on shower days and would note any skin impairments there. Resident 1 required enough assistance with ADLs (Activities of Daily Living) that her skin would be observed at least daily.
The current facility policy, titled Skin Management Program, with a most recent revision date of 05/22, was provided by the DON on 06/12/23 at 1:03 P.M. The policy indicated, .It is the policy .to ensure that each resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable .a resident with pressure ulcers receives necessary care and treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing .Interventions to prevent wounds from developing and/or promote healing will be initiated .
3.1-40(a)(1)
3.1-40(a)(2)