Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hickory Heights Health And Rehab, Llc during CMS and state inspections, most recent first.
Surveyors identified multiple deficiencies in food storage and handling, including unsealed and undated food items, improper separation of raw meats and vegetables, expired foods not discarded, and open containers in various storage areas. The Dietary Manager confirmed that these practices did not align with facility policies and could lead to contamination.
The facility failed to ensure proper food storage and handling practices, including maintaining appropriate temperatures in the walk-in refrigerator, covering and sealing opened food items, and following handwashing protocols. These deficiencies had the potential to affect 103 residents.
The facility failed to ensure dignity and privacy for two residents during care. One resident was exposed multiple times by a CNA during a shower and subsequent care, while another resident's abdomen was exposed during a tube feeding with the door open. Both staff members acknowledged the importance of maintaining privacy, but the facility lacked a policy on dignity.
The facility failed to ensure proper nail care for three residents with severe cognitive impairments, leading to observations of long, chipped nails with brown substances under them. Staff interviews confirmed that nail care was the responsibility of CNAs and nurses, but it was not adequately performed.
The facility failed to maintain a medication error rate of less than 5%, resulting in a rate of 19.23%. Multiple residents did not receive medications as prescribed, and the facility lacked a medication administration policy. Errors included incorrect dosages and missed medications, as confirmed by LPNs during the survey.
The facility failed to follow the planned menu for residents on pureed diets, serving incorrect portions of pureed spaghetti, omitting pureed bread, and using the wrong vegetable. This affected the nutritional intake of nine residents.
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets. Observations revealed that green beans, spaghetti with meat sauce, bread sticks, and sausage were not prepared to the appropriate consistency, affecting nine residents.
The facility failed to ensure proper hand hygiene among staff, leading to multiple deficiencies in infection control. A CNA did not sanitize her hands between changing gloves and before leaving a resident's room, while an LPN failed to sanitize hands between passing meal trays and administering medications to residents. Both staff members acknowledged the importance of hand hygiene and admitted to not following the protocol.
A resident with a history of cardiovascular accident and severe cognitive impairment was observed multiple times without a device for their contracted left hand. Despite the care plan and staff awareness, no hand roll or splint was applied, and the facility lacked a policy for managing contractures.
The facility failed to maintain a safe, functional, and sanitary environment in the men's secured unit. Observations revealed extensive peeling paint, gouged drywall, and large holes in the dining room walls. The Maintenance Director confirmed the issues had been present for two months without any work orders for repair.
Deficient Food Storage and Handling Practices Identified
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage and handling practices during a tour of the kitchen, freezer, refrigerator, dry storage, and cooking areas. In the freezer, there were unsealed and open boxes of frozen beef patties and fish fillets, as well as a metal container holding both undated, open bags of chopped greens and open bags of raw meats, which were not properly separated. The discard date on the container had passed, and the Dietary Manager acknowledged that raw meats and vegetables should not be stored together and that the meats should have been discarded. Additionally, boxes of chicken and pork were stored above greens, contrary to proper storage protocols. In the refrigerator, an unsealed bag of block cheese without a discard date and a box of scrambled egg mix stored below a box of turkey were found. In the dry storage area, unsealed drink mix bags without use-by dates and a dented can of ketchup were observed, with the Dietary Manager noting the risk of contamination from dented cans. In the cooking area, two seasoning containers were found with open, unsealed lids, which the Dietary Manager stated could allow bugs to enter. Facility policies reviewed indicated requirements for proper labeling, sealing, and storage of food items, as well as the separation of raw foods, which were not followed in these instances.
Improper Food Storage and Handling Practices
Penalty
Summary
The facility failed to ensure proper food storage and handling practices in the kitchen, which had the potential to affect 103 residents. Observations revealed that the walk-in refrigerator was at 55 degrees Fahrenheit, and milk stored inside was at 53 degrees Fahrenheit. Additionally, several opened boxes of food items in the walk-in refrigerator and freezer were not covered or sealed. An opened bottle of lemon juice was stored in the dry storage area instead of being refrigerated as per the manufacturer's instructions. These practices could lead to food spoilage and cross-contamination, posing a risk to residents' health. Dietary staff were observed not following proper handwashing techniques, which could lead to cross-contamination. One employee handled dirty dishes and then clean dishes without washing hands, while another wiped hands on their shirt and then handled clean utensils. Other staff members were seen turning off faucets with bare hands after washing, using contaminated gloves to handle food, and not washing hands after handling dirty objects. These actions compromised the cleanliness and safety of the food being prepared and served to residents. Hot food items on the steam table were not maintained at the required temperatures. Pureed cut green beans and mashed potatoes were found to be below the required temperature and were not reheated before being served. This failure to maintain proper food temperatures could result in foodborne illnesses. The facility's policy on handwashing was not adhered to by the dietary staff, further increasing the risk of contamination and illness among residents.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure dignity and privacy for two residents during care. Resident #10, diagnosed with Spastic Quadriplegic Cerebral Palsy, was observed by surveyors to be exposed multiple times by CNA #3 during a shower and subsequent care. The CNA did not use a bath blanket to cover the resident, exposing the resident's front body, back, buttocks, and legs while applying lotion and a barrier cream. The CNA confirmed that she should have used a bath blanket to maintain the resident's privacy during the care process. Resident #90, with a medical history including Hemiplegia and Chronic Systolic Heart Failure, was observed by a surveyor with their abdomen exposed while RN #1 administered a tube feeding. The door to the resident's room was open, compromising the resident's privacy. Both RN #1 and the DON acknowledged the importance of closing the door and pulling the privacy curtain to protect the resident's privacy and dignity. The facility did not have a policy on dignity when asked by the surveyor.
Failure to Provide Proper Nail Care
Penalty
Summary
The facility failed to ensure proper personal hygiene, specifically nail care, for three residents who were unable to perform activities of daily living due to cognitive impairments and limited mobility. Resident #2, with a BIMS score indicating severe cognitive impairment, was observed multiple times with long, chipped, and partially painted fingernails that had a dark brown substance under and around them. Similar observations were made for Resident #42 and Resident #73, both of whom also had severe cognitive impairments and were noted to have long, jagged nails with chipped polish and brown substances under their nails on several occasions. Interviews with facility staff, including CNAs, LPNs, and the DON, confirmed that nail care was the responsibility of CNAs unless the resident was diabetic, in which case nurses were responsible. Staff indicated that nail care was typically provided on shower days or as needed. However, the observations indicated that this care was not being adequately performed. The DON and other staff acknowledged that long, jagged nails and the presence of brown substances under nails could lead to skin tears and infections. The facility did not have a specific policy for nail care, as confirmed by the nurse consultant.
Medication Error Rate Exceeds Acceptable Limits
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5%, resulting in a medication error rate of 19.23%. This was observed through multiple instances where medications were not administered in accordance with physician's orders. For example, Resident #10, who had a diagnosis of Spastic Quadriplegic Cerebral Palsy, was supposed to receive 34 grams of Polyethylene Glycol Powder and 2 tablets of Senna daily. However, LPN #2 only administered 17 grams of Polyethylene Glycol and 1 tablet of Senna. LPN #3 confirmed the discrepancy and admitted that the orders were not followed correctly. Additionally, Resident #35 was supposed to receive 2000 mg of Fish Oil and 2 tablets of Vitamin D3, but only received 1000 mg of Fish Oil and no Vitamin D3. LPN #1 confirmed the error upon review of the MAR. Similarly, Resident #3 was supposed to receive 6 tablets, including Loratadine for allergies, but only received 5 tablets, missing the Loratadine. LPN #1 acknowledged the mistake during the medication pass review. The report also highlighted that the facility did not have a policy for medication administration, as confirmed by the nurse consultant. This lack of policy likely contributed to the medication errors observed. The surveyor's observations and interviews with the LPNs revealed a pattern of not adhering to the prescribed medication orders, which directly led to the high medication error rate. The facility's failure to ensure proper medication administration practices and the absence of a medication administration policy were significant factors in the deficiency identified by the surveyors.
Failure to Follow Planned Menu for Pureed Diets
Penalty
Summary
The facility failed to ensure that meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents. During the noon meal service, it was observed that dietary staff did not follow the menu for residents on pureed diets. Specifically, residents were served incorrect portions of pureed spaghetti, with some receiving only half the required amount. Additionally, pureed bread was not served to residents, and pureed cut green beans were used instead of the specified pureed vegetable blend. These discrepancies were confirmed through interviews with dietary staff, who admitted to not following the menu correctly. The dietary employee responsible for serving the meals acknowledged the errors, stating that they had forgotten to serve the pureed bread and had used the wrong portion sizes for the pureed spaghetti. The dietary supervisor also confirmed that the wrong vegetable was used, stating that the menu should have been followed as written. This failure to adhere to the planned menu had the potential to affect the nutritional intake of nine residents who were on pureed diets, as identified by the administrator.
Improper Pureed Food Consistency
Penalty
Summary
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets. During observations, it was noted that pureed green beans, spaghetti with meat sauce, bread sticks, and sausage were not prepared to the appropriate consistency. The green beans were thick, the spaghetti was chunky with visible pieces of noodles and meat, the bread sticks were lumpy and thick, and the sausage was gritty. These inconsistencies were confirmed by dietary employees and nursing staff when questioned by the surveyor. The deficiency was observed during multiple meal services, affecting the quality of food provided to residents on pureed diets. The dietary employees acknowledged that the pureed food items did not meet the required pudding-like consistency and admitted to not adding enough liquid to achieve the proper texture. The failure to properly puree the food items had the potential to affect nine residents who were documented to be on pureed diets, as per the list provided by the Administrator.
Infection Control Deficiencies Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to ensure proper hand hygiene practices among staff, leading to multiple deficiencies in infection control. One incident involved a Certified Nursing Assistant (CNA) who did not sanitize her hands between changing gloves and before leaving a resident's room. The CNA handled various items and performed personal care tasks for a resident with Spastic Quadriplegic Cerebral Palsy without following proper hand hygiene protocols. This included touching the resident's catheter bag, applying lotion and barrier cream, and handling the resident's personal items without sanitizing her hands or changing gloves appropriately. The CNA admitted to not following the hand hygiene protocol during an interview. Another deficiency was observed with a Licensed Practical Nurse (LPN) who failed to sanitize her hands between passing meal trays to residents. The LPN assisted residents with their food items and returned to the food cart multiple times without sanitizing her hands, increasing the risk of cross-contamination. The LPN acknowledged the importance of hand hygiene and admitted to not following the protocol during an interview. The Director of Nursing (DON) confirmed the necessity of sanitizing hands before and after passing meal trays to prevent contamination. Additionally, the same LPN was observed administering medications to residents without sanitizing her hands before and between medication passes. The LPN did not follow the hand hygiene protocol, which is crucial to prevent the spread of infections. Both the LPN and the DON confirmed the importance of sanitizing hands before and after administering medications to residents. The facility's Handwashing/Hand Hygiene policy emphasizes that hand hygiene is the primary means to prevent the spread of infection and must be performed even when gloves are used.
Failure to Provide Appropriate ROM Care for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) received appropriate care and services to prevent further decrease in ROM. Resident #19, who has a history of cardiovascular accident with hemiplegia and severe cognitive impairment, was observed multiple times without a device in place for their contracted left hand. Despite the care plan identifying the need for assistance with ADLs and the presence of a hand contracture, no hand roll or splint was applied. Interviews with the Director of Physical Therapy, Director of Nursing (DON), Licensed Practical Nurse (LPN), Restorative Aide (RA), and Restorative Nurse (RN) revealed a lack of awareness, communication, and follow-through regarding the resident's need for a hand roll or splint. The DON and other staff members acknowledged the importance of such devices but failed to ensure their application and maintenance. The DON confirmed awareness of the contracture but did not ensure the application of a hand roll, which was found to be foul-smelling and dirty when checked. The RA and RN admitted to discussing the contracture but did not take action to place the resident on restorative care or refer them to therapy. The RN mentioned that attempts to place a hand roll were discontinued because the resident found it painful, but no further efforts were made to address the issue. The facility also lacked a policy for managing contractures, contributing to the deficiency in care for Resident #19.
Unsafe and Unsanitary Conditions in Men's Secured Unit
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. During observation rounds on the men's secured unit, it was noted that the entire length of a 15-foot wall had peeling paint and gouged areas of drywall approximately 7 feet from the floor. The dining room walls in the men's secured unit had several areas with chipping paint and holes in the drywall. Specifically, there was a large hole near a window where residents eat their meals, measuring 4.5 x 2 inches, and another large hole beside a second dining table, measuring 6 x 4 inches. Additionally, there was a large area of peeling paint under the med-room window, measuring 23 x 17 inches in diameter, and another gash in the drywall measuring 2 x 1.25 inches, which was hanging from the wall and within reach of all residents. The Maintenance Director confirmed the poor condition of the walls and stated that the issues had been present since he started two months ago. Despite acknowledging the need for repainting, there were no work orders for the identified areas in the dining room. The Maintenance Director attributed the damage to residents peeling the paint off the walls and the impact of wheelchairs. The lack of timely maintenance and repair work contributed to the unsafe and unsanitary conditions observed in the men's secured unit.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pleasant Valley Rehabilitation And Nursing | 2.5 mi | — | 0 | 0 |
| The Springs Of Pinnacle Mountain | 2.8 mi | — | 9 | 0 |
| The Springs Of Chenal | 4.2 mi | — | 4 | 0 |
| The Blossoms At Breckenridge Rehab & Nursing Cente | 4.6 mi | — | 4 | 0 |
| Presbyterian Village, Inc | 4.7 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.