Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 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 House Nursing Home during CMS and state inspections, most recent first.
A resident, cognitively intact and on hospice care, had an order for morphine sulfate concentrate 20 mg/mL to be given as 5 mg PO q2h PRN for pain/SOB, with non-pharmacological interventions attempted first. Facility policy required adherence to the 10 Rights of Medication Administration and preparedness for opioid-induced respiratory depression. Despite this, documentation on the controlled medication record showed the resident was given 1 mL of morphine concentrate instead of the prescribed 0.25 mL. Nursing notes and an employee statement confirmed that an excess dose was administered, after which the resident developed increased lethargy and decreased BP and required two IM doses of Narcan, with subsequent improvement and return to baseline.
A resident filed a grievance alleging that a CNA was verbally disrespectful, threw a shirt at the resident, refused to assist with socks, and left the room without returning. The DON confirmed that this abuse allegation was not reported to the State agency as required by facility policy and state regulations.
A resident reported that a CNA spoke disrespectfully, threw a shirt at the resident, refused to help with socks, and left the room without returning. The DON confirmed that this abuse allegation was not fully investigated, as required by facility policy.
Surveyors found that three residents did not receive care according to physician orders, including administration of Midodrine and Metoprolol outside of specified blood pressure parameters and failure to adhere to a prescribed fluid restriction for a resident with CHF. These deficiencies were confirmed through record review and staff interviews.
A resident with a physician's order for oxygen therapy via nasal cannula did not have their equipment changed as directed, with observations showing the cannula was not replaced weekly and was visibly soiled, contrary to facility policy and medical orders.
The facility failed to thoroughly investigate incidents involving three residents. A resident with dementia was found with a bleeding wrist, but the incident report lacked key details. Another resident with severe cognitive impairment reported feeling unsafe and alleged abuse, but no staff statements were taken. A third resident had a pen found in their rectum, but the investigation did not include interviews or contact with the hospital. The facility's investigations were confirmed to be incomplete.
The facility failed to follow physician's orders and notify the physician of missed medications for three residents. One resident missed doses of Vancomycin due to unavailability, another received Coreg despite a low heart rate, and a third was given Midodrine outside of ordered parameters. The DON confirmed these deficiencies.
A resident with severe cognitive impairment and a history of dementia and CVA experienced two falls in one day due to inadequate supervision and assistance. The resident, requiring two-person assistance for transfers, fell while attempting to enter a family van without proper assessment and later during a one-person transfer from a wheelchair to a bed, contrary to their care plan.
A resident with COPD and other respiratory conditions was receiving supplemental oxygen without a physician's order, contrary to the facility's policy. The resident had been on continuous oxygen since admission, but the order was only documented after several days, following confirmation by the DON.
A resident was given antibiotics for a probable UTI without a proper nursing assessment or lab confirmation. The decision was made after a phone call with a doctor, and the resident received antibiotics for five days without microbiological evidence. The DON and Nursing Home Administrator confirmed the lack of assessment and lab study.
Significant Morphine Dosing Error Requiring Narcan Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from a significant medication error involving morphine administration. Facility policy on Administration of Medications required staff to follow the 10 Rights of Medication Administration, including the right drug, right resident, and right dose, and the policy on Opioid-Induced Respiratory Depression required preparedness to address opioid-related emergencies. The resident involved was cognitively intact, dependent on staff for ADLs, and admitted for long-term care, later admitted to hospice. A physician’s order on the resident’s MAR directed that morphine sulfate concentrate 20 mg/mL be given as 5 mg by mouth every 2 hours PRN for pain or shortness of breath, with documentation of three non-pharmacological interventions prior to use for pain. Despite this order, the Controlled Medication Utilization Record showed that the resident received 1 mL of morphine concentrate instead of the prescribed 0.25 mL, resulting in a dose above the ordered amount. A nursing progress note documented that the resident received an excess dose of morphine concentrate, with initial vital signs, neurological status, and mentation within normal limits, and an employee statement confirmed that the nurse administered more than the prescribed dosage. A subsequent nursing note recorded that the resident then exhibited increased lethargy and decreased blood pressure, and Narcan was administered intramuscularly twice for possible side effects from the increased morphine dose, after which blood pressure and mentation improved. Later documentation indicated the resident was monitored with vital signs within normal limits and remained responsive, and a physician note confirmed that the resident had received a morphine dose above the prescribed amount, became lethargic with decreased blood pressure, was treated with Narcan, and returned to baseline.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving one resident. According to facility policy, any alleged violations involving neglect, abuse, or misappropriation of resident property must be reported immediately to the administrator and as required by state law. A grievance was filed by a resident stating that a CNA spoke to him disrespectfully, threw a shirt at him, told him to put it on, refused to help him put on socks, and then left the room without returning. The Director of Nursing confirmed that this abuse allegation was not reported to the State agency as required by policy and regulation.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving one resident. According to facility policy, any reported or suspected incident of abuse, neglect, or exploitation requires an investigation by the administrator or designee, with protective measures implemented as needed. Documentation review showed that a resident filed a grievance stating that a CNA spoke to him disrespectfully, threw a shirt at him, told him to put it on, refused to assist with putting on socks, and then left the room without returning. An interview with the Director of Nursing confirmed that this abuse allegation was not fully investigated, contrary to facility policy and regulatory requirements.
Failure to Follow Physician Orders for Medication and Fluid Restriction
Penalty
Summary
The facility failed to follow physician orders for three residents, resulting in deficiencies related to medication administration and fluid restriction. For one resident with hypotension, Midodrine was administered multiple times despite blood pressure readings exceeding the physician-ordered threshold for withholding the medication. Documentation showed that the medication was given on several occasions when the systolic blood pressure was above 125 mm/Hg, contrary to the order. Another resident with acute congestive heart failure and malnutrition had a physician order for a strict fluid restriction, but records indicated that the resident consistently received fluids in excess of the prescribed daily limit over several days. Additionally, a third resident with hypertensive chronic kidney disease received Metoprolol Succinate ER outside of the specified blood pressure and heart rate parameters on four occasions. These findings were confirmed through review of clinical records, medication administration records, and staff interviews.
Failure to Follow Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to follow a physician's order for oxygen therapy for one resident. According to the clinical record, the resident had a current order to receive oxygen via nasal cannula, with instructions for the cannula to be changed every night shift on Wednesdays. Facility policy also required oxygen supplies, including cannulas, to be changed weekly and when visibly soiled, and to be labeled with the resident's name and the date of setup or change. Observations on two consecutive days revealed that the resident's nasal cannula was dated from several weeks prior and was visibly soiled, with red-tinged nasal prongs and brownish-red dots on the wrapping. The resident confirmed regular use of the oxygen equipment while in the facility.
Failure to Investigate Incidents Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate incidents involving three residents, as required by their policy on reducing the threat of abuse and neglect. For Resident 2, who has a history of dementia, anxiety disorder, and major depressive disorder, an incident occurred where the resident was found with a bleeding cut on the wrist. The incident report lacked documentation identifying the nurse who treated the wound and did not include any witness statements. The Nursing Home Administrator confirmed that the investigation was incomplete. Resident 95, who has severe cognitive impairment, reported feeling unsafe and alleged physical abuse by two men, described as EMT staff. The facility's documentation did not include statements from staff who had contact with the resident, and the Director of Nursing confirmed the lack of a comprehensive investigation into the allegation of physical abuse. For Resident 155, admitted after a hip fracture repair, an incident was reported where a pen was found in the resident's rectum. The facility's investigation did not include interviews with staff or residents, nor did it contact the hospital or transport company involved in the resident's admission. The Nursing Home Administrator and Director of Nursing confirmed the investigation was not thorough.
Failure to Follow Physician's Orders and Notify of Missed Medications
Penalty
Summary
The facility failed to follow physician's orders and notify the physician of missed medications for three residents. Resident 9 had a physician's order for Vancomycin to treat C-diff, but the medication was not administered until the morning of the last day of the order, missing three doses due to unavailability. The physician was not notified of the missed doses until several days later. Resident 51 received Coreg, a beta blocker, despite having a heart rate below the ordered parameter on multiple occasions over several months. The clinical records indicated that the medication was administered with a heart rate of less than 60, contrary to the physician's order. Resident 95 was administered Midodrine, a medication for low blood pressure, outside of the ordered parameters, as it was given 13 times with a systolic blood pressure above 130. The Director of Nursing confirmed that the medication was administered outside of the ordered parameters. These deficiencies indicate a failure to adhere to physician's orders and to communicate effectively with physicians regarding medication administration issues.
Failure to Provide Adequate Supervision and Assistance Leads to Resident Falls
Penalty
Summary
The facility failed to provide appropriate assessment and supervision to prevent falls for a resident with severe cognitive impairment and a history of dementia and cerebral vascular accident. The resident required extensive assistance with two persons for transfers using a hemi walker, as documented in their care plan. On January 1, 2024, the resident was found on the floor outside the facility after attempting to transfer into a family van without the necessary assistance. The rehabilitation department was not notified to assess the resident's safety with car transfers, which contributed to the incident. Later that same day, the resident experienced another fall when an aide attempted a one-person pivot transfer from a wheelchair to a bed, despite the care plan indicating the need for a two-person assist. The aide lowered the resident to the floor after the resident slipped during the transfer. Interviews with the Director of Nursing confirmed that the resident was not provided with the required two-person assistance, leading to two falls in one day.
Lack of Physician Order for Oxygen Use
Penalty
Summary
The facility failed to ensure a physician order for oxygen use was in place for a resident, identified as Resident 205, who was receiving supplemental oxygen. The facility's policy on oxygen administration, revised in February 2024, requires a written order specifying the liter flow needed by the resident. Resident 205, diagnosed with Chronic Obstructive Pulmonary Disease (COPD), bronchiectasis with an acute lower respiratory infection, and pleural effusion, was observed receiving supplemental oxygen at two liters per minute (LPM) via nasal cannula. Despite the resident's need for continuous supplemental oxygen since admission, there was no active physician's order documented in the clinical records. Interviews with Resident 205 revealed that they had been using supplemental oxygen as needed at home and required continuous oxygen since being admitted to the facility. The Director of Nursing confirmed the absence of a physician's order for the resident's supplemental oxygen from the time of admission. It was only on May 31, 2024, that a physician's order was documented, specifying oxygen administration at two to four LPM, with instructions to titrate to maintain saturation above 90% and notify the physician if needs could not be met at four liters.
Unnecessary Antibiotic Administration Due to Lack of Assessment
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, Resident 79 was administered an antibiotic without a proper nursing assessment or laboratory confirmation of a urinary tract infection (UTI). The resident had reported symptoms of dysuria and was noted to have blood on his penis and in his brief. Despite these symptoms, there was no documented nursing assessment to confirm the signs and symptoms reported by the CNA, nor was there any laboratory testing conducted to confirm a UTI before the administration of antibiotics. The decision to prescribe antibiotics was made after a phone call with the doctor's office, where it was noted that it was a Friday afternoon and the resident was symptomatic. The resident was subsequently given Amoxicillin-Pot Clavulanate for five days based on a diagnosis of probable UTI, without any microbiological evidence to support this diagnosis. The Director of Nursing and the Nursing Home Administrator confirmed the lack of a nursing assessment and laboratory study to confirm the infection and its sensitivity prior to the administration of the antibiotics.
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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 Honey Brook
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tel Hai Retirement Community | 1.7 mi | — | 2 | 0 |
| Inn At Freedom Village,the | 5.9 mi | — | 0 | 0 |
| Zerbe Sisters Nursing Center, | 7.7 mi | — | 0 | 0 |
| St Martha Center For Rehabilitation & Healthcare | 9 mi | — | 1 | 0 |
| Newport Meadows Health And Rehabilitation Center | 10.8 mi | — | 10 | 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.