Life Care Center Of Old Hickory Village
Inspection Findings
F-Tag F0657
F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
resident to the Elopement Book.Frequent monitoring q [every] 15min checks X [times] 72 hours.has impaired cognitive ability/impaired thought processes r/t [related to] vascular dementia. During a phone
interview on 10/8/2025 at 1:04 PM, Family Member U of Resident #4 was asked what was discussed in Resident #4's Care Plan meetings following the alleged elopement. The family member stated she had not participated in Care Plan meetings related to Resident #4. During an interview on 10/9/2025 at 3:35PM, the Social Service Director (SSD) was asked how often care conference meetings were conducted for Long Term Care residents. The SSD stated, .I try to have the care plan meetings done within 72-hours of admission. and as needed or if family requests them . During an interview on 10/9/2025 at 6:10 PM, the Director of Nursing (DON) was asked how often should care plan conferences be conducted. The DON stated, .at admission, quarterly or if there has been a significant change in condition. The DON was asked if care conference meetings were being conducted. The DON stated, .I assumed they had not been being done since they cannot find any care conference meeting notes .
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Printed: 04/13/2026 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
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/09/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Life Care Center of Old Hickory Village
1250 Robinson Road Old Hickory, TN 37138
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)
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
was the care plan followed. The DON stated, I do not know that it was not done. The DON was asked when intervals are in place should the monitoring be documented. The DON stated, Yes. The DON was asked were every 30-minute checks while in bed documented on Resident #1 on 4/4/2025 before she had the incident in her room. The DON stated, It should be documented. I will have to go look and see, it may be in
the chart . The DON failed to provide documentation that Resident #1 was monitored every 30 minutes while in bed, before her fall on 4/4/2025. The facility failed to follow the care plan intervention to prevent a fall. During an interview on 10/9/2025 at 6:25 PM, the Administrator was asked who told him about Resident #1's injury to the arm on 4/4/2025. The Administrator stated, The DON told to me of the incident.
The Administrator was asked did the DON tell him that the resident had to have surgery. The Administrator stated, .do not recall . The Administrator was asked if there was a Performance Improvement Plan (PIP) related to Resident #1's injury. The Administrator stated, Do not recall, I do not know what the DON implemented, no PIP. If it was, it would have been presented in QAPI [Quality Assurance and Performance Improvement] .
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LIFE CARE CENTER OF OLD HICKORY VILLAGE in OLD HICKORY, TN inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in OLD HICKORY, TN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LIFE CARE CENTER OF OLD HICKORY VILLAGE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.