Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens 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 Sunset during CMS and state inspections, most recent first.
A resident with a history of falls was injured when her wheelchair, lacking foot pedals, was pushed over a floor dip by a bus driver, causing her to fall and sustain a nasal fracture. Staff interviews revealed uncertainty about foot pedal requirements, and the facility lacked a policy on their use.
A Nursing Assistant in Training (NAIT) failed to follow proper handwashing procedures during a meal service, washing hands for less than 20 seconds and not using a paper towel to turn off the faucet before serving trays to residents. The Director of Nursing confirmed that the NAIT had been trained on the correct technique, which is outlined in the facility's hand hygiene policy.
A resident with quadriplegia and dysphasia was not served a meal tray during lunch, despite requesting a hamburger substitute in advance. The meal was delayed as the kitchen staff had to procure the hamburger externally, causing the resident distress. Discrepancies were noted in whether the resident was offered an alternative meal while waiting.
The facility failed to properly label and dispose of medications, including undated and expired eyedrops and solutions, as observed during a survey. Medications for residents with conditions like diabetes and glaucoma were not managed according to policy, leading to potential risks. The facility's policies on medication storage and expiration were not followed, resulting in these deficiencies.
A resident with PTSD and anxiety experienced psychosocial distress due to the facility's failure to provide appropriate services. The resident was left unattended in the shower room multiple times, exacerbating his anxiety and feelings of abandonment. Despite having a PTSD diagnosis, the facility did not conduct a trauma assessment or develop a trauma-informed care plan, leading to the deficiency.
A resident was left without transportation after a hospital appointment due to the facility's failure to coordinate and communicate transportation arrangements. Despite being assured that transportation was arranged, the resident was left outside the hospital and unable to contact the facility for assistance. An off-duty employee eventually brought the resident back to the facility.
A resident with multiple health conditions, including paraplegia and gastro-esophageal reflux disease, reported that the facility failed to honor his dietary dislikes and preferences, such as avoiding gassy, spicy, and greasy foods. Despite communicating these needs to the dietitian and staff, the resident continued to receive inappropriate meals, and no care plan was documented to address his dietary preferences. The Administrator acknowledged the issue but did not implement alternative communication methods or create a food preference list.
Resident Falls Due to Lack of Wheelchair Foot Pedals
Penalty
Summary
The facility failed to ensure the safe transportation of a resident in a wheelchair, resulting in a fall and nasal fracture. Resident B, who was admitted with a right shoulder and hip fracture, was being transported by the facility's bus driver to an appointment. During the transport, the bus driver pushed the resident's wheelchair over a dip in the floor, causing the resident's foot to catch on the floor. The resident was not using foot pedals at the time, which led to her falling face-first out of the wheelchair, resulting in a sprained foot, a fractured nose, and a black eye. Interviews with staff revealed that the resident's sneakers caught on the floor, contributing to the fall. The bus driver attempted to prevent the fall by grabbing the resident's shoulders but was unsuccessful. It was noted that the resident's wheelchair did not have foot pedals in place during the incident, and there was uncertainty among staff about whether foot pedals were required. The facility did not have a policy regarding the use of foot pedals at the time of the incident. The resident's medical records indicated she was cognitively intact and dependent on staff for mobility. The fall was witnessed, and the resident experienced pain and bruising. The facility's fall management policy required comprehensive, resident-centered fall prevention plans, but the lack of foot pedals during transport was identified as a contributing factor to the fall.
Improper Handwashing During Meal Service
Penalty
Summary
The facility failed to ensure proper handwashing procedures during a lunch meal service, as observed on 9/5/24. A Nursing Assistant in Training (NAIT) was seen washing hands for less than the required 20 seconds and turning off the water faucet without using a paper towel as a barrier. This improper hand hygiene was followed by the NAIT serving meal trays to multiple residents in the dining room. During an interview on 9/10/24, the Director of Nursing (DON) confirmed that all staff should be aware of the proper handwashing technique, and the NAIT had been trained on this procedure. The facility's hand hygiene policy, revised in 7/2022, clearly outlines the steps for proper handwashing, including rubbing hands for at least 20 seconds and using a paper towel to turn off the faucet.
Failure to Ensure Resident Dignity During Meal Service
Penalty
Summary
The facility failed to ensure the dignity of a resident, identified as Resident B, during a meal service. During a lunch observation, Resident B, who required substantial assistance with eating due to quadriplegia and dysphasia, was not served a meal tray while another resident at the same table was assisted with their meal. Resident B had requested a hamburger as a substitute meal prior to being brought into the dining room, but the meal was delayed because the kitchen staff had to procure the hamburger from outside the facility. This resulted in Resident B having to wait for her meal, which she expressed was upsetting. Interviews conducted revealed discrepancies in the accounts of whether Resident B was offered an alternative meal while waiting. The Certified Food Manager indicated that Resident B was offered something else, which she declined, while the Executive Director mentioned that cottage cheese was offered. However, Resident B did not recall being offered any alternative and stated she would have accepted cottage cheese if it had been offered. The facility's policy on resident rights, which includes the right to be treated with dignity and to decide on meals, was provided by the Executive Director.
Medication Labeling and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and disposal of medications and biologicals, as observed during a survey. An opened and undated bottle of Brimonidine eyedrops was found in the West/North medication cart, intended for a resident with type two diabetes. The facility's policy was not to use eyedrops after 30 days of opening, but the Director of Nursing (DON) indicated that the expiration date depended on the medication. Additionally, an opened bottle of Latanoprost eyedrops with an expired use-by date was found, and it was unclear if it had been administered past its expiration. This medication was for a resident diagnosed with glaucoma. Another deficiency was noted with an opened and undated bottle of Refresh Relieva eyedrops, which lacked a current physician's order. The historical order for these drops had been discontinued, and the nurse confirmed they should have been discarded. Furthermore, an opened and undated multidose vial of Lidocaine HCL 1% solution was found, which was used to reconstitute a resident's Ceftriaxone injection. The facility's policy required such vials to be dated when opened. The survey also found a container with five vials of Tuberculin solution, one of which was opened and undated, in the back hall medication room. The facility's policy required opened vials to be dated and discarded within 30 days. The DON provided several policies and guidelines, including those for storage and expiration dating of medications, which were not adhered to, leading to these deficiencies.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide appropriate services to a resident with a history of post-traumatic stress disorder (PTSD) and anxiety, resulting in psychosocial distress. The resident, who was alert and meticulous in record-keeping, reported severe abandonment anxiety stemming from a traumatic incident involving his wife. Despite being aware of his mental health issues, the facility did not offer him psychiatric services, and he relied on external psychiatric care. The resident experienced multiple instances of being left unattended in the shower room, which exacerbated his anxiety and feelings of abandonment. On several occasions, the resident was left in the shower room without assistance, despite having a call light that was supposed to alert staff. The call light cord was initially extended with a string, which was later removed due to safety concerns, and replaced with a bell that was ineffective in summoning help. The resident reported being left for extended periods, including one instance where he was left for about 1.5 hours, causing him to become upset and fearful. He also experienced a lack of communication and support during a hospital visit for an MRI, where he was left waiting for transportation back to the facility, further contributing to his distress. The facility's documentation lacked evidence of a trauma assessment or a care plan for trauma-based care, despite the resident's PTSD diagnosis. The care plans in place addressed anxiety and depression but did not incorporate trauma-informed care practices. The facility's policy on trauma-informed care required referrals to behavioral health services and the development of a care plan, which was not evident in the resident's medical record. This oversight in providing trauma-informed care and ensuring the resident's psychosocial well-being led to the deficiency noted in the report.
Failure to Arrange Transportation for Resident
Penalty
Summary
The facility failed to assist Resident G in obtaining transportation from a hospital appointment, resulting in the resident being left without a way to return to the facility. On 5/28/24, Resident G was sent to the hospital for an MRI and was assured by a nurse that his transportation was arranged. However, after completing the MRI, Resident G was left outside the hospital as the transportation van did not arrive. Despite his attempts to contact the facility for assistance, no one answered his calls for about 30 minutes. An off-duty employee of the facility, who happened to see Resident G outside the hospital, eventually brought him back to the facility. Interviews with facility employees revealed a lack of communication and coordination regarding Resident G's transportation. Employee 3, who encountered Resident G at the hospital, observed him making multiple unsuccessful calls to the facility. Upon contacting the facility, Employee 3 was informed by a supervisor that no one was aware of the transportation arrangements. Additionally, Employee 5 confirmed that there was confusion among staff about who was responsible for Resident G's pickup, and no one had the transportation company's contact information. Resident G's medical record indicates he has multiple diagnoses, including paraplegia, diabetes, generalized anxiety disorder, and major depressive disorder, which may have exacerbated his distress during the incident.
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to honor a resident's dietary dislikes and food preferences, specifically for Resident G, who was one of the three residents reviewed for food preferences. Resident G, who suffers from paraplegia, gastro-esophageal reflux disease, diabetes, generalized anxiety disorder, and major depressive disorder, reported that he cannot tolerate gassy, spicy, or greasy foods due to digestive issues related to his paralysis. Despite having communicated these preferences to the dietitian upon admission and repeatedly informing the staff, Resident G continued to receive meals that did not align with his dietary needs, such as sausage and eggs, and sausage pizza, which he could not tolerate. The facility's failure was further highlighted by the absence of a documented care plan addressing Resident G's dietary preferences in his medical record. The Administrator acknowledged that the diet ticket did not reflect the resident's dislikes, attributing it to the resident's alleged frequent changes of mind. However, no food preference list was created for Resident G, and the Administrator admitted to not exploring alternative communication methods for the resident to express his preferences. This deficiency was noted in relation to a complaint, and the facility's policy on Residents Rights emphasized the right to reasonable accommodation of needs and preferences, which was not upheld in this case.
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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 Greencastle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Asbury Towers Health Care Center | 0.7 mi | — | 10 | 0 |
| Waters Of Greencastle, The | 1.3 mi | — | 12 | 0 |
| Mill Pond Health Campus | 1.4 mi | — | 0 | 0 |
| Aperion Care Summerfield | 9.2 mi | — | 0 | 0 |
| Cloverleaf Of Knightsville | 14 mi | — | 6 | 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.