Inspection·June 30, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based upon clinical record review, it was determined the facility failed to follow physician orders for medication administration for two of 18 residents reviewed (Resident 22 and Resident 63). Residents Affected - Few Findings include: Review of Resident 22's physician orders dated June 2, 2023, revealed an order for Ampicillin-Sulbactam (antibiotic medication) Sodium Intravenous Solution 3 grams to be administered intravenously every 6 hours for a right foot infection. Review of Resident 22's June Medication Administration Record (MAR) failed to reveal evidence that Resident 22 received the antibiotic medication as ordered by the physician on June 28, 2023, at 6:00 a.m. Interview with the Assistant Director of Nursing on June 30, 2023, at 10:00 a.m. confirmed Resident 22 did not receive the antibiotic medication as ordered by the physician. Review of Resident 63's physician orders dated May 31, 2023, revealed an order for Lorazepam (anti-anxiety medication) 0.5 milligrams (mg) to be administered daily at 8:00 a.m. Review of Resident 63's clinical progress notes revealed Resident 63 was administered Lorazepam 0.5 mg on June 14, 2023, at 2:15 a.m. Resident 63 was then unable to receive the scheduled dose at 8:00 a.m. Interview with the Assistant Director of Nursing on June 30, 2023, at 10:05 a.m. confirmed Resident 63 received Lorazepam 0.5 mg at 2:15 a.m. on June 14, 2023, instead of receiving it at 8:00 a.m. as ordered by the physician. The facility failed to ensure medications were administered according to physician orders. 28 Pa. Code 211.12(d)(1)(5) Nursing Services Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 395436 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hickory House Nursing Home 3120 Horseshoe Pike Honey Brook, PA 19344 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)