Life Care Center Old Hickory: Care Plan Failures - TN
The October inspection at Life Care Center of Old Hickory Village revealed that Resident #1 had a care plan requiring monitoring every 30 minutes while in bed to prevent falls. But when the resident fell on April 4, 2025, staff had no documentation showing they followed this safety protocol.
The Director of Nursing couldn't provide records proving the required checks occurred before the fall. When inspectors asked whether 30-minute monitoring should be documented, the DON responded: "Yes." Asked specifically about documentation for Resident #1 on April 4 before her incident, the DON said: "It should be documented. I will have to go look and see, it may be in the chart."
No such documentation was found.
The fall resulted in an arm injury severe enough to require surgery. Yet when inspectors interviewed the facility administrator about the incident, he displayed striking gaps in knowledge about what happened to the resident under his facility's care.
Asked who told him about Resident #1's arm injury on April 4, the administrator said the Director of Nursing informed him of the incident. But when inspectors asked whether the DON mentioned the resident needed surgery, the administrator stated: "Do not recall."
The administrator also couldn't remember whether the facility implemented any Performance Improvement Plan following the resident's injury. "Do not recall, I do not know what the DON implemented, no PIP," he told inspectors. "If it was, it would have been presented in QAPI."
The inspection found the facility failed to follow its own care plan intervention designed to prevent exactly this type of fall. Federal regulators classified the violation as causing "actual harm" to the resident.
Care plans in nursing homes serve as roadmaps for resident safety, outlining specific interventions based on individual risk factors. When facilities identify residents at high risk for falls, they must implement and document monitoring protocols to prevent injuries.
The 30-minute monitoring requirement for Resident #1 suggests she had been assessed as having significant fall risk. Such frequent checks are typically reserved for residents with conditions like dementia, mobility issues, or medication effects that increase their likelihood of falling.
Falls represent one of the most serious safety risks in nursing homes. When residents fall, they can suffer fractures, head injuries, and other complications that may require hospitalization or surgery. The consequences can be particularly severe for elderly residents whose bones may be more fragile.
The inspection revealed a troubling pattern of administrative disconnect from resident care. The facility's top administrator couldn't recall whether a resident under his oversight had surgery following an injury, or whether any quality improvement measures were implemented afterward.
This lack of administrative awareness raises questions about oversight systems at the facility. Quality Assurance and Performance Improvement programs are designed to help nursing homes identify problems and prevent their recurrence. When administrators can't remember basic details about serious resident injuries, it suggests gaps in these safety systems.
The Director of Nursing's inability to produce documentation of the required monitoring checks points to potential problems with staff compliance and record-keeping. In nursing homes, documentation serves not just as a regulatory requirement but as a critical communication tool between shifts and departments.
When safety protocols aren't documented, there's no way to verify they occurred. This creates risks for residents and makes it difficult to identify patterns or problems that need correction.
The inspection occurred in response to a complaint, suggesting someone outside the facility raised concerns about the resident's care. Complaint investigations often reveal problems that might otherwise go undetected during routine inspections.
Resident #1's case illustrates how breakdowns in basic safety protocols can have serious consequences. A simple requirement to check on a fall-risk resident every 30 minutes, when not followed, led to an injury requiring surgical intervention.
The facility's failure to maintain proper documentation and administrative oversight compounds the original safety violation, creating a pattern of deficient care that put the resident at unnecessary risk.
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.
But when the resident fell on April 4, 2025, staff had no documentation showing they followed this safety protocol.
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.