Hickory Creek At Franklin

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to notify the physician of a weight gain of more than 5 pounds in a week in accordance with the written plan of care for 1 of 16 residents reviewed for physician's orders. (Resident 36)Finding includes: On 2/10/26 at 12:15 p.m., Resident 36's clinical record was reviewed. The diagnoses included, but were not limited to, end stage renal disease and dependence on renal dialysis. A Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident 36 had moderate cognitive impairment. A Physician's Order, initiated 4/22/25, indicated to weigh Resident 36 every Monday, Wednesday, Friday if weight gain of more than 3 pounds in a day or 5 pounds in a week notify the physician. On 9/3/25 Resident 36's weight was 154.7 pounds and on 9/5/25 the weight was 161.6, which indicated a weight gain of 6.9 pounds. On 10/10/25 Resident 36's weight was 167.5 pounds and on 10/13/25 the weight was 201.2, which indicated a weight gain of 33.7 pounds. On 1/7/26 Resident 36's weight was 151.6 pounds and on 1/9/26 the weight was 159.2, which indicated a weight gain of 7.6 pounds. The facility lacked documentation for physician notification regarding the greater than five-pound weight gain for Resident 36 on 9/5/25, 10/12/25, and 1/9/26. During an interview on 2/11/26 at 8:04 a.m., the Director of Nursing Services indicated there should have been physician notifications as per physician orders. On 2/11/26 at 8:27 a.m., the Executive Director indicated that the facility did not have a policy on following physician orders. The facility was to follow Federal guidelines. On 2/10/26 at 9:00 a.m., the Executive Director provided a policy titled Dialysis Care with a revision date of 11/2017. A review of the policy indicated Procedure, .1. Physician orders will be received at time of admission specific to the residents; Weight monitoring if indicated. 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident received the correct diet as ordered by the physician for 1 of 1 residents reviewed for diet order. (Resident 228)
Finding includes:
During an interview on 4/2/24 at 9:00 a.m., Resident 228 indicated she did not like the food at the facility. It's terrible.
On 4/2/24 at 12:30 p.m., Resident 228 was observed in the main dining room. Resident 228's meal consisted of, but was not limited to, pureed cornbread and pureed salad.
On 4/4/24 at 8:30 a.m., observed Resident 228 in her room. Resident 228's bedside table was sitting next to her bed. The breakfast tray was sitting on top and included scrambled eggs and ham in pureed consistency.
On 4/4/24 at 12:57 p.m., observed a bedside table in Resident 228's room. The table had her lunch tray sitting on top. The tray consisted of, but was not limited to, meatballs in pureed consistency and green beans in pureed consistency.
On 4/2/24 at 1:15 p.m., the clinical record of Resident 228 was reviewed. The diagnosis included, but was not limited to, dysphasia.
An admission MDS (Minimum Data Set) assessment, dated 4/4/24, indicated Resident 228 had moderate cognitive impairment.
A care plan dated 4/4/24 and current through 7/4/24, indicated Resident requires mechanically altered diet related to dysphasia. Goal: Resident will tolerate current diet consistency without signs/symptoms of difficulty chewing/swallowing. Approach: .Honor known food preferences and provide diet per MD order.
A physicians order, dated 3/29/24 with no end date, indicated Resident 228 was to receive a Regular, Soft Bite-Sized diet.
During an interview on 4/4/24 at 9:59 a.m., the Dietary Manager indicated the facility followed the physicians orders and a diet guide sheet. The diet guide sheet specified if the resident was to receive pureed or bite sized consistency for each food item.
On 4/4/24 at 11:30 a.m., the Dietary Manager provided a diet Guide Sheet, dated 2023. The guide sheet indicated the following food items should be served in the following consistency for a soft and bite sized diet:
- Sweet and sour meatballs should be soft and bite sized.
- green beans should be soft and bite sized.
- corn bread should be soft and bite sized.
During an interview on 4/4/24 at 1:11 p.m., the Regional Nurse consultant indicated the green beans and meatballs should have been soft and bite sized as ordered by the physician.
On 4/4/24 at 12:30 p.m., the Administrator provided a policy titled General Food Preparation and Handling, dated June 2023, and indicated it was the current policy being used by the facility. A review of the policy indicated .14. Recipes will be followed as written. 15. Food will be altered to the appropriate consistency to meet individual needs of the residents.
3.1-21(a)(3)

Based on observation, interview, and record review, the facility failed to ensure infection control procedures were completed for 1 of 5 residents reviewed for resident care. Glove changes and hand hygiene was not performed. (LPN 2, Resident 11)
Findings include:
On 4/3/24 at 12:55 p.m., Resident 11's clinical record was reviewed. The diagnoses included, but were not limited to, obstructive and reflux uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow; back-up of urine into the kidneys) and chronic kidney disease.
The Physician Orders included, but were not limited to, the following:
- catheter order: foley catheter (device that helps drain urine from the bladder) care, every shift, start date of 3/9/24 with no end date indicated.
-bilateral buttocks treatment: MASD [moisture associated skin damage, inflammation of the skin] .cleanse area with Medline Hydrating Spray Cleaner, pat dry, MIX 1:1 Calmoseptine and House antifungal cream and apply to bilateral buttocks every shift, start date 4/2/24 with no end date indicated.
The admission Minimum Data Set (MDS) assessment, dated 3/15/24, indicated Resident 11 was mildly cognitively impaired, had an indwelling urinary catheter, and had MASD to the bilateral buttocks.
Resident 11's care plans included, but were not limited to the following:
Problem: Resident has impaired skin integrity: Dermatitis rash to bilateral buttocks [related to] fecal incontinence .Start date - 3/26/24 and current through 6/26/24 .Approach: treatment as ordered .
Problem: Resident requires an indwelling urinary catheter [related to] obstructive uropathy .Start date - 3/13/24 and current through 6/20/24 .Approach: provide assistance for catheter care .
On 4/2/24 at 10:34 a.m., Resident 11 was observed resting in bed. A covered urinary catheter bag and catheter tubing were observed hanging on the bed rail.
During an interview at that time, Resident 11 indicated he has had a urinary catheter for a while and had a sore on his back.
On 4/4/24 at 2:15 p.m., Licensed Practical Nurse (LPN) 2 was observed providing catheter care and bilateral buttocks care to Resident 11. The following was observed:
- Resident 11 was resting in bed on his back. The urinary catheter bag and catheter tubing were observed hanging on the bed rail.
- LPN 2 donned the plastic PPE (personal protective equipment - gown and two sets of plastic gloves) and placed the urinary catheter care and bilateral buttocks care supplies on the over-bed table located next to Resident 11's bed.
- LPN 2 performed urinary catheter care. LPN 2 was not observed to change the gloves or conduct hand hygiene prior to transitioning from a contaminated (dirty) area to a non-contaminated (clean) area.
- LPN 2 then assisted Resident 11 to turn onto his left side to begin the bilateral buttocks care. Upon turning the resident, LPN 2 observed Resident 11 had been incontinent of bowel. A red-colored rash was observed on Resident 11's buttock area.
- LPN 2 walked to Resident 11's closet, approximately 10 feet from the bed, to retrieve a clean incontinent brief and handy wipes. LPN 2 then performed incontinent care to Resident 11. The soiled incontinent brief and wipes were placed on top of the bed linens at the foot end of the bed. LPN 2 was not observed to change the gloves or conduct hand hygiene prior to transitioning from the contaminated area to a clean area.
- LPN 2 then performed the bilateral buttocks treatment care by cleansing the area with Medline Hydrating Spray Cleaner and patted dry the exposed area. LPN 2 was not observed to change the gloves or conduct hand hygiene prior to transitioning from the contaminated area to a clean area.
- Using the left hand, LPN 2 picked up the previously prepared medicine cup of Calmoseptine and House antifungal cream and placed her right index finger into the medicine cup. LPN 2 turned toward the resident.
Just prior to LPN 2 having reached Resident 11 with the medicine cup in hand, LPN 2 indicated during an interview at that time, she had spaced having to change the gloves and perform hand hygiene when going from a contaminated [dirty] area to a clean area. LPN 2 then asked if she should change the gloves before continuing the treatment.
- LPN 2 then walked to the PPE supply storage unit, located on the floor at the foot end of Resident 11's bed. LPN 2 removed the original gloves, applied hand sanitizer, and donned new gloves.
- LPN 2 picked up the original medicine cup that contained the Calmoseptine and House antifungal cream. LPN 2 indicated at that time, she was using the left side of the cup since she had previously put her finger in the right side of the cup. LPN 2 then applied the Calmoseptine and House antifungal cream.
During an interview on 4/5/24 at 8:55 a.m., the Corporate Nurse Consultant indicated staff were to conduct hand hygiene and change gloves during personal care when going from a contaminated area to a clean area.
During an interview on 4/5/24 at 9:57 a.m., the Director of Nursing Services (DNS) indicated staff were to wash hands and change gloves during personal care when going between contaminated and clean areas.
On 4/5/24 at 8:55 a.m., the Corporate Nurse Consultant provided a copy of the Standard and Transmission-Based Precautions (isolation) policy, dated September 2023, and indicated it was the current policy in use by the facility. A review of the document indicated, .prevent the spread of infection from resident to resident .hand hygiene: hand washing .hand rub .perform hand hygiene: before having direct contact with a resident; before performing clean/aseptic procedure; after contact with the resident; after contact with .body fluids .contaminated surfaces; after touching resident surroundings .Gloves: wear gloves when it can be anticipated that contact with .body fluids .change gloves during care and perform hand hygiene if hands will move from a contaminated site to a clean site .
3.1-18(b)(1)

Based on interview and record review, the facility failed to complete a thorough investigation for an allegation of physical abuse for 1 of 3 residents reviewed for abuse. (Resident B)
Finding includes:
During an interview on 12/13/23 at 10:44 a.m., LPN 1 (Licensed Practical Nurse) indicated on 12/7/23 at approximately 2:00 p.m., Resident B indicated they were going to get her that night. When LPN 1 asked who Resident B was talking about, Resident B indicated a tall male night nurse and a female night nurse.
During an interview on 12/13/23 at 10:30 a.m., Family Member 1 indicated on 12/8/23, Resident B called Family Member 1 and indicated a large black female nurse and a tall, skinny, white male nurse beat her and raped her on night shift. Family Member 1 was not sure what night Resident B was talking about. Family Member 1 notified the Administrator on 12/8/23.
During an interview on 12/13/23 at 10:57 a.m., the Administrator indicated on 12/7/23, Resident B reported that the night shift nurses beat her up. First Resident B's described the staff as 2 females and a male, all of them German. Then Resident B indicated it was a tall male and one female. On 12/8/23, Resident B's daughter called the Administrator and indicated Resident B called and indicated Resident B was beaten and raped on night shift. The description Resident B gave her daughter of the night nurses was a large black female nurse and a tall, skinny, white male nurse. The physical description Resident B gave to the Administrator matched the description of CNA 1 and LPN 2. CNA 1 and LPN 2 worked night shift on 12/6/23. Resident B made the allegation about the night shift nurses on 12/7/23 at approximately 2:00 p.m. Both CNA 1 and LPN 2 were allowed to return to work for night shift on 12/7/23, because Resident B indicated the alleged perpetrators were German. At that time, the facility did not have any nurses that were German that worked in the facility. The description Resident B gave didn't match the nurses that were working at that time so the facility closed the investigation.
During an interview on 12/13/23 at 11:05 a.m., the DON (Director of Nursing) indicated she did not complete a thorough interview with CNA 1 nor LPN 2 regarding the allegation of physical abuse made by Resident B on 12/7/23. The DON reviewed the facility's abuse questionnaire with CNA 1 and LPN 2.
During an interview on 12/13/23 at 11:56 a.m., the ADON (Assistant Director of Nursing) indicated she had not witnessed nor heard about any abuse in the facility, but on 12/7/23 the ADON completed interviews with CNA 1 and LPN 2 regarding the allegation Resident B made, on 12/7/23. The ADON reviewed the abuse questionnaire with CNA 1 and LPN 2.
The clinical record for Resident B was reviewed on 12/13/23 at 8:27 a.m. The diagnoses included, but were not limited to, mood disorder, anxiety disorder, and cognitive communication deficit.
The Annual MDS (Minimum Data Set) assessment, dated 10/10/23, indicated Resident B was cognitively intact.
A witness statement, dated 12/7/23, indicated Resident B indicated to LPN 1 they were really going to get her that night. LPN 1 asked what they looked like and Resident B indicated there were 2 women and one man. The man was tall and laughed a lot. He laughed when he hurt Resident B. The man and women were German.
A witness statement, dated 12/7/23 at 2:05 p.m., indicated Resident B indicated to LPN 1 that the two night shift nurses from last night were trying to kill her and that was why Resident B was so sore. The two night shift nurses beat her up really bad. Resident B told LPN 1 to be careful who LPN 1 told.
On 12/13/23 at 1:22 p.m., the DON provided a copy of a document, titled Staff Abuse Questionnaire, dated 12/7/23, and indicated this was the abuse questionnaire that was reviewed with CNA 1. A review of the abuse questionnaire indicated CNA 1 did not witness any employee, resident, nor visitor abuse or mistreat another resident. CNA 1 was not suspicious of any employee mistreating residents. CNA 1 did not witness any employee acting frustrated, stressed, short, fatigued, irritable, isolated, nor showing other signs of burnout. CNA 1 did not witness any employee treat residents unkindly, laugh at residents, rush or perform care roughly, use unsafe practices, nor treat resident in an inappropriate manner. CNA 1 had not seen any unusual bruises, markings, nor witnessed a resident act guarded nor fearful. The signature line for CNA 1 indicated over the phone. The Staff Abuse Questionnaire was reviewed with CNA 1 by the ADON. The document lacked a completed thorough interview with CNA 1 regarding the physical abuse allegation involving CNA 1, that Resident B reported on 12/7/23.
On 12/13/23 at 1:22 p.m., the DON provided a copy of a document, titled Staff Abuse Questionnaire, dated 12/7/23, and indicated this was the abuse questionnaire that was reviewed with LPN 2. A review of the abuse questionnaire indicated LPN 2 did not witness any employee, resident, nor visitor abuse or mistreat another resident. LPN 2 was not suspicious of any employee mistreating residents. LPN 2 did not witness any employee acting frustrated, stressed, short, fatigued, irritable, isolated, nor showing other signs of burnout. LPN 2 did not witness any employee treat residents unkindly, laugh at residents, rush or perform care roughly, use unsafe practices, nor treat resident in an inappropriate manner. LPN 2 had not seen any unusual bruises, markings, nor witnessed a resident act guarded nor fearful. The signature line for LPN 2 indicated over the phone. The Staff Abuse Questionnaire was reviewed with LPN 2 by the ADON. The document lacked a completed thorough interview with LPN 2 regarding the physical abuse allegation that involved LPN 2, Resident B reported, on 12/7/23.
A daily staffing report, dated 12/6/23, indicated LPN 2 and CNA 1 were the only nursing staff that worked night shift.
A daily staffing report, dated 12/7/23, indicated LPN 2 and CNA 1 were the only nursing staff that worked night shift.
During an interview on 12/13/23 at 10:20 a.m. CNA 1 (Certified Nursing Aide) indicated CNA 1 worked night shift on 12/6/23 from approximately 10:00 p.m. until 12/7/23 at approximately 6:00 a.m. CNA 1 worked night shift again on 12/7/23 from approximately 10:00 p.m. until 12/8/23 at approximately 6:00 a.m. The first time CNA 1 was interviewed regarding an abuse allegation that involved CNA 1 and LPN 2 was after his shift ended on 12/8/23.
The clinical record lacked documentation of a completed thorough investigation that included interviews with LPN 2 and CNA 1 that included facts and observations regarding the physical abuse allegation made by Resident B on 12/7/23 before CNA 1 and LPN 2 returned to work for night shift on 12/7/23.
On 12/13/23 at 9:02 a.m., the Administrator provided a copy of a facility policy, titled Abuse Prohibition, Reporting, and Investigation, dated 2/2010, and indicated this was the current policy used by the facility. A review of the policy indicated any staff member implicated in the alleged abuse will be removed from the facility at once and will remain suspended until an investigation is completed. The investigation will include facts and observations by involved employees. All residents will be protected from physical harm during an investigation by implementing staffing changes, if necessary, to protect the residents from the alleged perpetrator.
This citation relates to Complaint IN00423709.
3.1-28(d)

Based on observation, interview, and record review, the facility failed to ensure infection control practices implemented to mitigate the spread of COVID-19 for 2 of 3 residents reviewed for infection control. A staff member entered a resident's room with droplet precautions without eye protection and 2 staff members where observed not wearing a facemask inside the facility as indicated on the sign posted at each entrance to the facility. (Resident B, CNA 1, CNA 2, Maintenance Director)
Finding includes:
1. On 9/27/23 at 9:00 a.m., observed the Maintenance Director walk through a hallway approximately 4 feet from multiple residents sitting in the hallway without a facemask on.
On 9/27/23 at 1:12 p.m., observed CNA 2 in a resident room with both residents in the room. CNA 2 was kneeling between the 2 beds approximately five feet from each resident. CNA 2 was not wearing a facemask. CNA 2 picked up a clear garbage bag that contained a soiled brief then walked out of the room. At that time, CNA 2 indicated she should have re-applied the facemask after the resident pulled it off of her face. CNA 2 pulled an intact, folded, face mask out of her pocket and put the mask on her face.
During an interview on 9/27/23 at 1:17 p.m., the Maintenance Director indicated a facemask was required while in the facility.
2. During an interview on 9/27/23 at 9:45 a.m., CNA 1 (Certified Nursing Aide) indicated Resident B was in isolation precautions for testing positive for COVID-19. At that time, the door to Resident B's room was closed. There was a red sign on Resident B's door that indicated droplet/contact precautions and a gown, gloves, N95 mask, and eye protection were required to enter Resident B's room. Observed CNA 1 knock on Resident B's door and open the door. CNA 1 walked into the room and walked toward Resident B's roommate but within 4 feet of Resident B. Resident B was not wearing a face mask and the privacy curtain was not fully pulled to separate the room. Then CNA 1 exited the room. At that time, CNA 1 indicated eye protection was required to enter the room and she should have worn a face shield into the room.
The clinical record for Resident B was reviewed on 9/27/23 at 11:37 a.m. The diagnoses included, but were not limited to, COVID-19, diabetes, and morbid obesity.
An admission MDS (Minimum Data Set) assessment, dated 9/12/23, indicated Resident B was cognitively intact.
A progress note, dated 9/25/23 at 12:08 p.m., indicated exposure testing took place. Resident B tested positive with a point of care antigen test. Resident B was noted to have a cough, congestion, fatigue, and shortness of breath. Resident B was placed in droplet/contact isolation for 10 days.
A physicians order initiated on 9/25/23, indicated Resident B droplet/contact isolation due to a highly transmissible pathogen, related to COVID-19.
On 9/27/23 at 9:27 a.m., the Administrator provided a copy of a facility policy, titled COVID-19 Policy, dated 7/2023, and indicated this was the current policy used by the facility. A review of the policy indicated this community will implement infection control practices to reduce the risk of transmission of COVID-19. Residents and staff that reside or work on a unit or area of the facility experiencing a COVID-19 outbreak when the source of COVID-19 cannot be determined through contact tracing.
This Federal tag relates to Complaint IN00416222.
3.1-18(b)(1)