Hickory Ridge Nursing & Rehabilitation Center

Inspectors wroteBased on observations, interviews and facility policy review, the facility failed to ensure clean food service areas. This had the potential to affect all residents who received meals from the kitchen. The facility did not identify any residents who received nothing by mouth. The facility census was 141.

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to honor preferences. This affected six residents (#9, #17, #71, #105, #106, and #129) out of six residents for beverage preferences. This had the potential to affect 141 residents who received meals from the facility. No residents were identified as receiving nothing by mouth (NPO). The facility census was 141.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure staff utilized appropriate hand hygiene during medication administration. This affected four residents (#27, #68, #105, and #116) out of eight residents observed for medication administration. The facility census was 141.

Inspectors wroteBased on medical record reviews, observations, interviews, personnel file review, and employee handbook review, the facility failed to ensure resident respect and dignity was maintained when Certified Nursing Assistants (CNA) acted in an unprofessional manner while working in the facility. This affected two residents (Resident #01 and #85) out of eight residents reviewed for abuse. The facility census was 141.

Inspectors wroteBased on interview, medical record review, personnel file review, and policy review, the facility failed to implement their abuse protocol when an allegation of verbal abuse was reported to staff. This affected one resident (Resident #80) of seven residents reviewed for abuse. The facility census was 141. Findings Include: Resident #80 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, high blood pressure, atrial fibrillation, dementia without behavioral disturbance, anxiety disorder, high risk heterosexual behavior, major depressive disorder, and liver cell carcinoma. Review of the comprehensive Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #80 was cognitively intact and exhibited no behaviors. Review of the nursing notes revealed an Interdisciplinary Team (IDT) note dated 12/19/25 at 12:28 P.M. [...]

Inspectors wroteBased on medical record review, observations, interviews, and facility policy reviews, the facility failed to ensure a thorough investigation was completed for verbal abuse during a self-reported incident (SRI) investigation. This affected one (Resident #85) out of eight residents reviewed for abuse. The facility census was 141. Findings Include:Review of the medical record for Resident #85 revealed an admission date on 08/25/22 with diagnoses including, but not limited to, unspecified dementia, alcohol dependence with alcohol-induced dementia, vascular dementia, anxiety, depression, insomnia, encephalopathy, and unspecified psychosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #85 had a Brief Interview Mental Status (BIMS) score of 09 indicating impaired cognition. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe smoking interventions were in place for Resident #106 and failed to ensure fall interventions were implemented at all times for Resident #16 and Resident #25. This affected three residents (Resident #16, Resident #25, and Resident #106) out of eight residents reviewed for accidents. The facility census was 141.1. Review of the medical record for Resident #106 revealed an admission date of 05/17/17. Diagnoses included but not limited to chronic atrial fibrillation, chronic obstructive pulmonary disease and nicotine dependence. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #106 had intact cognition and required supervision for activities of daily living. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper diets were followed. This affected three residents (Residents #17, #71, and #106) out of five residents for nutrition. The facility census was 141.1. Review of the medical record for Resident #17 revealed an admission date of 12/19/25. Diagnoses included but not limited to fracture of the upper end of right tibia, muscle weakness, and osteoarthritis. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #17 had intact cognition and required supervision for eating and partial assistance for other activities of daily living. Review of the physician's orders for January 2026 revealed that Resident #17 was ordered a regular diet with regular texture and thin liquids diet with double entrees all meals, eggs grits and meat related to at risk for malnutrition. [...]

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure respiratory equipment was maintained in a sanitary manner and oxygen orders were individualized to meet resident specific needs to reduce the risk of complications from variations in oxygen treatment. This affected two (Residents #127 and #136) of two residents reviewed for respiratory care with the potential to affect 20 residents who utilized oxygen. The facility census was 141.

Inspectors wroteBased on staff interviews, medical record review, and facility policy review, the facility failed to ensure a resident who required dialysis received ongoing assessments of condition before and after dialysis treatments. This affected one Resident (#14) of one resident identified as receiving dialysis. The facility census was 141. Review of the medical record for Resident #14 revealed an admission date of 06/19/19 and diagnoses including end stage renal disease (ESRD), diabetes mellitus, dependence on renal dialysis, morbid obesity, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF). Review of the plan of care dated 05/13/20 revealed Resident #14 received dialysis treatments three times per week for ESRD. It was noted Resident #14 frequently refused to go to dialysis treatments. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure behavioral health interventions were implemented for Resident #45 with PICA (a mental health condition where a person eats things that aren't food). This affected one resident (Resident #45) out of three residents reviewed for behaviors. The facility census was 141.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #135's medical record was complete and accurate to reflect secured unit placement. This affected one resident (Resident #135) of three residents reviewed for medical records related to behavioral health services.

Inspectors wroteBased on observation, record review, interview, policy and procedure review, and review of the Centers for Disease Control (CDC) guidance, the facility failed to ensure staff performed appropriate hand hygiene and ensure all staff implemented enhanced barrier precautions. This affected two of three residents reviewed for incontinence care (Residents #65 and #8) and one of 20 residents who ate their meals and resided on the 100 hall (Resident #58). These failures also had the potential to affect all 20 residents currently residing on the 100 hall (Residents #8 #17, #25, #37, #58, #65, #71, #74, #75, #78, #94, #95, #105, #109, #117, #135, #137, #139, #143 and #146). The facility census was 147.

Inspectors wroteBased on record review and staff interview the facility failed to ensure Resident #65's care plan clearly reflected interventions to be used for safe transfer. This affected one (#65) out of three residents reviewed for falls. The facility census was 147.

Inspectors wroteBased on observation, record review, interview, and review of the nursing assistant job description, the facility failed to ensure Resident #17 was consistently assisted with shaving his facial hair on a daily basis. This affected one (#17) out of three residents reviewed who were dependent of staff for assistance with their activity of daily living (ADL) needs. The facility census was 147.

Inspectors wroteBased on record review, resident and staff interviews, and policy and procedure review, the facility failed to ensure the safe transfer of Resident #65 resulting in a fall and failed to maintain Resident #137's care planned interventions to prevent falls. This affected two (#65 and #137) of three residents reviewed for falls. The facility census was 147.

Inspectors wroteBased on record review, interview, and review of the American Nurses Association (ANA) guidelines for accuracy of documentation, the facility failed to ensure staff accurately documented the presence of interventions to prevent a fall. This affected one of three residents reviewed for falls (Resident #137). The facility census was 147.

Inspectors wroteBased on medical record review, observation, and interview the facility failed to provide oral care in a timely manner. This affected one (Resident #1) of three residents reviewed for activities of daily living. The census was 139.

Inspectors wroteBased on interviews with residents, interview with dietary staff, review of a test tray, and review of the facility policy the facility failed to ensure foods were palatable and served at appropriate temperatures. This had the potential to affect 127 residents who received food from the kitchen. The facility identified one resident (#117) as receiving nothing by mouth. The facility census was 128.

Inspectors wroteBased on observation, interview and policy review the facility failed to ensure the kitchen floor, storage areas and equipment was maintained in a clean manner, foods were properly stored in the refrigerator and freezer, and foods were served to the residents in a sanitary manner. This had the potential to affect all 146 residents currently residing in the facility who received food prepared in the kitchen.

Inspectors wroteBased on observation and interview the facility failed to provide a safe, functional, sanitary and comfortable environment for all residents. This affected 27 (Resident #13, #21, #22, #26, #33, #35, #43, #48, #52, #63, #67, #79, #81, #93, #96, #100, #104, #107, #112, #123, #129, #130, #131, #131, #133, #138, #147) currently residing on the 600 unit. The facility census was 147.

Inspectors wroteBased on interview and record review the facility failed to develop and implement an individualized meal plan to meet Resident #22's needs. This affected one (Resident #22) of eight residents reviewed for nutrition.

Inspectors wroteBased on record review, observation, interview, and policy review the facility failed to ensure medication was properly administered via a percutaneous endoscopic gastrostomy (peg) tube. This affected one resident (Resident #139) of four residents observed for medication administration. There was only one resident identified with a gastrostomy tube in the facility.