Life Care Center Old Hickory: Harm From Hazards - TN
The incident occurred on April 4, 2025, when Resident #1 suffered an injury in her room that necessitated surgical intervention. Federal inspectors found the facility had established a care plan calling for staff to check on the resident every 30 minutes while she was in bed, but failed to document these crucial safety monitoring visits.
When questioned by inspectors on October 9, the facility's Director of Nursing could not explain whether the monitoring protocol was actually followed. "I do not know that it was not done," the DON stated when asked if the care plan was implemented.
The DON acknowledged that monitoring intervals should be documented when they are in place. When inspectors specifically asked whether every 30-minute checks were documented for Resident #1 on April 4 before her fall, the DON responded: "It should be documented. I will have to go look and see, it may be in the chart."
Despite this promise to locate the records, the DON ultimately failed to provide any documentation showing that Resident #1 was monitored every 30 minutes while in bed before her fall. The facility's failure to follow its own care plan intervention represented a breakdown in fall prevention protocols.
The Administrator's knowledge of the incident appeared limited during the inspection interview conducted at 6:25 PM on October 9. When asked who informed him about Resident #1's arm injury, he stated the DON had told him about the incident.
However, the Administrator's recall of crucial details proved spotty. When inspectors asked whether the DON had informed him that the resident required surgery, the Administrator responded: "Do not recall."
The facility's response to the serious incident also raised concerns about quality improvement processes. When asked if there was a Performance Improvement Plan related to Resident #1's injury, the Administrator stated: "Do not recall, I do not know what the DON implemented, no PIP."
The Administrator noted that if such a plan existed, "it would have been presented in QAPI," referring to the facility's Quality Assurance and Performance Improvement program. The absence of any documented improvement plan following a fall that required surgery suggests gaps in the facility's incident response procedures.
The inspection findings highlight a cascade of failures in resident safety protocols. The facility had recognized Resident #1 as requiring enhanced monitoring through the establishment of 30-minute checks, indicating an awareness of her fall risk. Yet when the monitoring system was needed most, it appears to have broken down entirely.
Federal inspectors determined the violation resulted in actual harm to few residents, with the severity reflecting the surgical intervention required after the fall. The facility's inability to produce monitoring documentation despite having a clear care plan requirement represents a fundamental failure in following established safety protocols.
The case illustrates how documentation failures can mask whether critical care interventions are actually being performed. Without records of the required 30-minute checks, there is no way to verify that staff were providing the enhanced monitoring deemed necessary for Resident #1's safety.
The DON's uncertain responses about basic care plan implementation and the Administrator's limited recall of a surgery-requiring incident suggest broader concerns about management oversight and incident tracking at the facility.
Resident #1's fall and subsequent surgery occurred despite having a specific care plan designed to prevent exactly this type of incident through regular monitoring. The facility's failure to document these safety checks leaves unanswered whether the fall might have been prevented through proper implementation of the established protocol.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Life Care Center of Old Hickory Village from 2025-10-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
LIFE CARE CENTER OF OLD HICKORY VILLAGE in OLD HICKORY, TN was cited for violations during a health inspection on October 9, 2025.
The incident occurred on April 4, 2025, when Resident #1 suffered an injury in her room that necessitated surgical intervention.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.