Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around October 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 Creek At Crawfordsville during CMS and state inspections, most recent first.
A QMA repeatedly failed to perform required hand hygiene while administering and preparing medications for multiple residents during meal service. The QMA handled personal items such as hair, removed food from a resident’s clothing, and touched another resident’s shirt between direct resident contacts and medication passes, without washing or sanitizing hands as required by facility policy. The facility’s medication policy required appropriate hand hygiene before and after direct resident contact, but these practices were not followed.
Surveyors found that a QMA routinely crushed and mixed multiple oral medications in applesauce for two residents, including memantine, aspirin EC, and potassium ER, despite pharmacy guidance and reference materials indicating these products should not be crushed. One resident had vascular dementia and swallowing difficulties, while the other had a history of stroke and vascular dementia without a swallowing disorder. The QMA reported she always crushed all medications for these residents, either due to swallowing problems or to improve acceptance. Although the facility had a General Dose Preparation and Medication policy requiring adherence to pharmacy guidelines and a pharmacy-supplied “do not crush” list, there was no formal, specific policy on crushing medications, and the listed non-crush medications were still altered during administration.
The facility did not ensure RN coverage for at least 8 consecutive hours on multiple days, as shown by staffing records and PBJ data. The Executive Director confirmed awareness of these lapses and acknowledged the regulatory requirement.
A resident with COPD and respiratory failure was observed multiple times with their nebulizer mask left un-bagged on the bedside table, contrary to facility policy requiring sanitary storage of respiratory equipment. Staff confirmed the expectation for proper storage, but the mask was not maintained in a safe and sanitary manner after use.
An LPN was observed placing a shared glucometer directly on a medication cart without a barrier and cleaning it with a hand sanitizing wipe instead of the approved disinfectant. The DON confirmed that facility policy requires the use of specific germicidal wipes and a clean barrier for glucometer disinfection, which was not followed in this instance.
The facility failed to ensure a Registered Nurse (RN) was present for 8 consecutive hours during a 24-hour period on multiple occasions in the first quarter of 2024. The Regional Director of Clinical Services (RDCS) confirmed the lack of RN coverage on specified dates and noted the absence of a Director of Nursing Services (DNS) and a related policy.
The facility failed to ensure proper labeling and disposal of medications for two medication carts. An undated eye drop solution and two insulin pens, one undated and one expired, were found. Staff were unsure of the policies regarding medication expiration.
The facility failed to ensure that personal funds were available on weekends for a resident who was cognitively intact. Interviews revealed that the Business Office Manager was unaware of the weekend procedure, and neither the LPN nor the RN knew of any money bag or cash box for weekend access. The facility had not had consistent business office staff, and both staff and residents needed education on the procedure for obtaining personal funds on weekends.
The facility failed to ensure that two dependent residents were shaved due to a shortage of razors, despite their care plans requiring assistance with personal hygiene. Staff interviews revealed issues with the ordering process, and the facility lacked a specific policy on maintaining an adequate supply of razors.
The facility failed to ensure dining meal service was completed in a sanitary manner. An RN and a CNA were observed assisting two residents by cutting their sandwiches with ungloved hands. The Regional Director of Clinical Services confirmed that this practice was inappropriate and against Indiana retail food guidelines.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure hand hygiene was completed according to infection control practices during medication administration for five of six residents reviewed. On 1/13/26 at 7:50 a.m., a Qualified Medication Aide (QMA 10) was observed passing medications during breakfast in the main dining room. After handing one resident a cup of medications and while waiting for the resident to swallow, QMA 10 removed a piece of bacon from another resident’s shirt, lifted her long hair from her neck, scratched her head, and ran her fingers through her hair. When the resident finished taking the medications, QMA 10 returned to the medication cart and began setting up medications for another resident without washing or sanitizing her hands. At 8:11 a.m., QMA 10 spoon-fed a resident crushed medications in applesauce and, while walking back to the medication cart, tweaked another resident’s shirt as she joked with her, again without performing hand hygiene before setting up medications for the next resident. At 8:21 a.m., QMA 10 administered medications to another resident and returned to the medication cart without washing or sanitizing her hands before preparing medications for yet another resident. At 8:27 a.m., QMA 10 administered medications to that resident and did not wash or sanitize her hands before starting to set up the next medication. The facility’s General Dose Preparation and Medication policy, revised 11/15/24, indicated that appropriate hand hygiene should be performed before and after direct resident contact, which was not followed in these observed instances.
Improper Crushing of Non-Crush Medications During Medication Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered according to manufacturer specifications, specifically by improperly crushing medications that should not be altered. During a morning medication pass in the main dining room, a QMA crushed and spoon-fed memantine tablets mixed in applesauce to a resident with vascular dementia, severe cognitive impairment, and documented swallowing difficulties. The physician’s orders allowed crushing of appropriate medications, but memantine was listed by the contracted pharmacy on a “do not crush” list, and a medication reference from the Mayo Clinic indicated memantine tablets should not be crushed, chewed, or divided because crushing can cause the drug to release too quickly into the body. In a separate observation, the same QMA crushed and spoon-fed aspirin EC (enteric coated), Jardiance (empagliflozin), and potassium chloride ER (extended release) mixed together in applesauce to another resident with a history of stroke and vascular dementia, who had severe cognitive impairment but no signs or symptoms of a swallowing disorder. The physician’s orders also allowed crushing of appropriate medications, but aspirin EC and potassium ER were on the pharmacy’s “do not crush” list. ISMP guidance indicated enteric-coated and ER medications should not be crushed or dissolved, and FDA information described potassium chloride ER as a formulation intended to slow potassium release. The QMA stated she always crushed all medications for these residents and administered them mixed together in applesauce, doing so for one resident due to swallowing problems and for the other because she took them better that way. The Regional Nurse Consultant indicated there was no formal facility policy for crushing medications, although a pharmacy-provided list of medications that should not be crushed was available, and the facility’s General Dose Preparation and Medication policy required staff to crush oral medications only in accordance with pharmacy guidelines and/or facility policy.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours each day, as required by regulation. Review of the Payroll Based Journal (PBJ) report during the entrance conference revealed that on multiple dates within one quarter, there was no documentation of RN coverage for any shift. Specifically, the staffing sheets for eight separate dates lacked evidence of an RN working in the facility. During an interview, the Executive Director confirmed awareness of the lack of RN coverage on the identified dates and acknowledged the expectation to comply with the regulation. The deficiency was based on both the PBJ report and the absence of RN documentation on the facility's staffing sheets for the specified dates.
Nebulizer Mask Not Stored Safely After Use
Penalty
Summary
A deficiency was identified when a resident's nebulizer mask was repeatedly observed left un-bagged on the bedside table during multiple random observations throughout the day. The nebulizer mask was not stored in a safe and sanitary manner as required by facility policy, which specifies that nebulizer equipment should be placed in a plastic bag when not in use. These observations were made despite the resident having recently received a nebulizer treatment, as documented in the medication administration record. The resident involved had diagnoses including chronic obstructive pulmonary disease (COPD) and both acute and chronic respiratory failure with hypercapnia, requiring regular nebulizer treatments as ordered by a physician. Interviews with the Assistant Director of Nursing confirmed the expectation that nebulizer masks should be stored in a bag when not in use, and the Director of Nursing provided the facility's policy supporting this procedure. The failure to properly store the nebulizer mask constituted a lapse in maintaining safe and sanitary respiratory care for the resident.
Failure to Follow Infection Control Procedures for Shared Glucometer
Penalty
Summary
A Licensed Practical Nurse (LPN) was observed performing a blood glucose assessment for a resident using a shared glucometer. After completing the assessment, the LPN placed the glucometer directly on top of the medication cart without using a barrier, contrary to facility policy. The LPN then used a hand sanitizing wipe, rather than the approved disinfecting wipe, to clean the glucometer and wrapped it in the wipe before placing it into a plastic cup. During an interview, the LPN confirmed that hand sanitizing wipes were used for cleaning the glucometer after use. The Director of Nursing (DON) later clarified that the facility's policy requires the use of specific germicidal wipes for disinfecting shared glucometers and mandates the use of a clean barrier when placing the device on solid surfaces. The DON confirmed that the hand sanitizing wipes used by the LPN were not the approved type for disinfecting glucometers. The facility's policy also specifies that the glucometer should remain wet with the disinfectant for the recommended contact time and be allowed to air dry on a clean barrier before reuse. These procedures were not followed during the observed incident.
Failure to Ensure RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was present for 8 consecutive hours during a 24-hour period on multiple occasions in the first quarter of 2024. Specifically, the Payroll-Based Journal (PBJ) Staffing report indicated that there was no RN coverage on 10/23, 10/29, 12/3, 12/9, 12/10, 12/14, 12/16, 12/17, 12/23, 12/24, 12/25, and 12/30. This was confirmed by the Regional Director of Clinical Services (RDCS) during an interview, who reviewed the PBJ data and staffing schedules and acknowledged the lack of RN coverage on the specified dates. The RDCS also noted that the facility did not have a Director of Nursing Services (DNS) at the time, and a float DNS was not present on those days. The RDCS further indicated that the facility did not have a policy related to RN coverage. This lack of policy and the absence of a DNS contributed to the failure to maintain the required RN coverage. The deficiency was identified through record reviews and interviews conducted on 5/22/24, where it was confirmed that the facility did not meet the regulatory requirement of having an RN on duty for 8 consecutive hours each day for the specified dates.
Improper Medication Labeling and Disposal
Penalty
Summary
The facility failed to ensure medications were labeled properly and expired medications were disposed of appropriately for two medication carts reviewed. On one occasion, an undated and opened bottle of eye drop solution for a resident was found in the front hall medication cart. The Qualified Medication Aide (QMA) confirmed that eye drops should be dated when opened and are good for 28 days. The resident's physician order indicated the use of the eye drops twice a day. In another instance, an undated and opened insulin pen for a resident was found in the back hall medication cart. Additionally, another insulin pen with an open date far exceeding the 28-day limit was also found in the same cart. The Licensed Practical Nurse (LPN) was unsure of the policy regarding the duration insulin pens are good for once opened. The Regional Director of Clinical Services confirmed that insulin pens should be discarded after 28 days. The residents involved had diagnoses including type 2 diabetes mellitus with complications such as diabetic neuropathy.
Failure to Ensure Weekend Access to Personal Funds
Penalty
Summary
The facility failed to ensure that personal funds were available on the weekends for Resident 19, who was cognitively intact according to a quarterly Minimum Data Set (MDS) assessment. During an interview, Resident 19 indicated she had not been able to access her money on weekends for a while. The Business Office Manager (BOM) confirmed that residents could only obtain their money Monday through Friday and was unaware of the weekend procedure. The Corporate Business Office Specialist mentioned that a money bag should be kept at the nurse's station for weekend access, but was unsure of its exact location at this facility. Additionally, the facility had not had consistent business office staff for some time, and both staff and residents needed education on the procedure for obtaining personal funds on weekends. Further interviews revealed that neither the Licensed Practical Nurse (LPN) nor the Registered Nurse (RN) were aware of any money bag or cash box being available for personal funds on weekends. The RN mentioned that the Director of Nursing had recently purchased a cash box, but staff had not yet been educated on its use. The Regional Director of Clinical Services provided an undated document titled 'Resident Trust Overview,' which indicated that funds should be available to residents 24/7 and that a method for distributing funds after hours and on weekends must be established. However, this policy was not being followed at the time of the survey.
Failure to Ensure Residents Were Shaved
Penalty
Summary
The facility failed to ensure that dependent residents were shaved, leading to deficiencies in personal hygiene for two residents. Resident 30, who had a seizure disorder and was on anticoagulant medication, was observed with long facial hair on multiple occasions. The resident expressed that he had not been shaved for quite a while due to the facility running out of razors. His care plan indicated he required assistance with ADLs, including shaving during showers, but records showed he had not been shaved for several days in May 2024. Similarly, Resident 17, who had hypertensive heart disease, chronic kidney disease, and diabetes, was also observed with long facial hair. The resident indicated he had not been shaved for several days and depended on staff for shaving during showers or bed baths. Despite his care plan requiring assistance with ADLs, including shaving, records showed he had not been shaved for several days in May 2024. The resident was finally shaved after the facility received a new supply of razors. Interviews with staff, including the Regional Director of Clinical Services, a CNA, and the Administrator, revealed that the facility had issues with the ordering process, leading to a shortage of razors. The Administrator acknowledged that the facility could have purchased razors locally to meet the residents' needs. The facility lacked a specific policy on maintaining an adequate supply of razors, although the expectation was to always have enough supplies on hand to meet residents' needs.
Unsanitary Dining Meal Service
Penalty
Summary
The facility failed to ensure dining meal service was completed in a sanitary manner. During an observation, a Registered Nurse (RN) was seen assisting a resident by cutting her sandwich while holding it with her ungloved left index finger. Similarly, a Certified Nursing Assistant (CNA) was observed assisting another resident by pushing down on the resident's sandwich with her ungloved hand while cutting it. The Regional Director of Clinical Services confirmed that it was inappropriate for staff to touch resident food items with ungloved hands, and the facility was expected to follow the Indiana retail food guidelines, which mandate minimizing bare hand contact with exposed food.
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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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Nursing homes near Crawfordsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lane House, The | 1.1 mi | — | 4 | 1 |
| Wellbrooke Of Crawfordsville | 1.3 mi | — | 7 | 0 |
| Ben Hur Health And Rehabilitation | 1.8 mi | — | 2 | 0 |
| Homewood Health Campus | 22.3 mi | — | 1 | 0 |
| Witham Extended Care | 22.3 mi | — | 0 | 0 |
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