Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Life Care Center Of Hickory Woods during CMS and state inspections, most recent first.
Kitchen sanitation was not maintained as required by facility policy. Surveyors observed food debris on and inside the deep fryer, oil dripping onto the floor, black dried liquid substance behind and around the stove, oven, deep fryer, and ice machine, along the baseboards and corners, and food debris with carbon buildup on the stovetop. The DD stated these conditions should not have been present.
Delayed and Unsigned MDS Assessments: The facility failed to complete and sign MDS assessments within required time frames for three residents. One resident with fx of the L femur, osteoporosis, and dementia had an annual MDS with the completion date left blank, another resident with dysphagia, GI hemorrhage, and GERD had a quarterly MDS with the completion date left blank, and a third resident with DM, CVA, dementia, and dysphagia had a late quarterly MDS plus an annual MDS with the completion date left blank. The MDS Coordinator stated the assessments should have been completed and submitted within 14 days of the ARD.
Failure to use PPE and perform proper catheter care: Staff did not follow enhanced barrier precautions or contact precautions for two residents. One CNA performed urinary catheter care for a resident with an indwelling catheter without a gown and did not cleanse the urinary meatus or insertion site, while two CNAs entered another resident’s contact isolation room without PPE. The ICP, ADON, and DON confirmed the expected PPE and catheter care practices.
A resident with severe cognitive impairment and multiple medical conditions was found to have their call light on the floor, out of reach, contrary to the facility's policy. Staff confirmed that call lights should be within reach, but this was not the case during an observation, leading to a deficiency in accommodating the resident's needs.
The facility failed to report an alleged abuse incident within the required 2-hour timeframe. A resident with no cognitive impairment reported being hit by another resident with severe cognitive impairment. The incident was not reported to the state agency until the following day, exceeding the facility's policy requirements.
A resident admitted to hospice care did not have a Significant Change MDS assessment completed, as required by facility policy and the RAI Manual. Despite severe cognitive impairment and hospice enrollment, the necessary assessment was not performed, and hospice care was not documented in the Quarterly MDS. Interviews with facility staff confirmed the oversight.
The facility failed to update care plans for several residents, leading to deficiencies in care management. A resident's care plan was not updated after discontinuing an antipsychotic medication, and another's was not revised after a Foley catheter was removed. Two residents involved in altercations did not have their care plans updated with necessary interventions. Additionally, a resident's care plan was not revised after a fall, and another's did not include hospice care despite an order for such services.
The facility failed to provide timely incontinence care for six residents, with significant delays in call light responses, especially during meal times. Residents reported waiting up to three hours for assistance, leading to discomfort and hygiene issues. Staff interviews revealed confusion about care priorities during meal service, contributing to the deficiency.
A resident with respiratory conditions did not receive CPAP treatment with oxygen as ordered by the MD on several occasions. The facility's TAR lacked documentation for these treatments, which were supposed to be administered during the dayshift. The DON confirmed the absence of documentation, which is against the facility's policy requiring immediate documentation after treatment.
A resident with multiple health conditions experienced inadequate pain management, as the facility failed to administer prescribed Tramadol and relied on Tylenol, which was insufficient. The resident's severe pain hindered therapy progress, and staff interviews revealed poor communication and coordination regarding pain management needs.
A facility failed to ensure proper pharmaceutical services and medication tracking for a resident. Medications brought in by a family member were not documented or administered as ordered, and there was no procedure for tracking these medications. Interviews revealed a lack of policy for documenting receipt and disposition of such medications, leading to a gap in pharmaceutical services.
A facility failed to maintain a functional resident call system, as required by policy. The call light in a resident's room was found without a cord, making it unusable. An LPN observed the call light on the floor, and a CNA found the cord with exposed wires. The Maintenance Director was unaware of the issue.
Kitchen Sanitation Deficiency
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment during food service operations. Facility policy titled Food Safety and Sanitation.Cleaning Schedule required a routine cleaning schedule to keep the department maintained in a clean and sanitary manner, but observations in the kitchen revealed food debris on top of and inside the deep fryer, oil dripping from the fryer onto the floor, black dried liquid substance on the floor behind and around the stove, oven, deep fryer, and ice machine, black dried liquid substance along the baseboards and in the corners, and food debris and carbon buildup on the stovetop. During interview, the Dietary Director stated there should not be black dried liquid substances on the floor and there should not be food debris or carbon buildup on the stovetop.
Delayed and Unsigned MDS Assessments
Penalty
Summary
The facility failed to ensure that resident assessments were updated at least every 3 months and that MDS assessments were signed to reflect timely submission within the required regulatory time frames for 3 of 23 sampled residents. The MDS 3.0 RAI Manual states that quarterly assessments must be completed at least every 92 days following the previous OBRA assessment and that the MDS completion date must be no later than 14 days after the ARD. The facility policy also stated that it would follow the RAI User's Manual when completing the MDS, Care Area Assessment, and Comprehensive Care Plan. Resident #5, who had diagnoses including fracture of the left femur, osteoporosis, and dementia, had an annual MDS with item Z0500B left blank even though it should have been completed by 11/14/2025. Resident #92, who had diagnoses including dysphagia, gastrointestinal hemorrhage, and GERD, had a quarterly MDS with item Z0500B left blank even though it should have been completed by 11/12/2025. Resident #148, who had diagnoses including diabetes, cerebral infarction, dementia, and dysphagia, did not have a quarterly MDS completed by 9/27/2025, and the annual MDS also had item Z0500B left blank even though it should have been completed by 11/4/2025. During interview, the MDS Coordinator stated that Residents #5, #92, and #148's MDS assessments should have been completed and submitted within 14 days of the ARD date.
Failure to Use PPE and Perform Proper Catheter Care
Penalty
Summary
The facility failed to ensure infection control practices were followed for residents requiring enhanced barrier precautions and contact precautions. Review of CDC guidance and facility policies showed that gown and glove use was required for high-contact care activities, including urinary catheter care, and that catheter meatal care should include cleaning the urinary meatus and periurethral area. The facility also had policies requiring appropriate PPE for contact precautions before entering a resident’s room. Resident #135 was admitted with diagnoses including multiple rib fractures, UTI, urinary retention, and neuromuscular dysfunction of the bladder. The resident had an indwelling catheter and was ordered enhanced barrier precautions every shift. During observation, CNA C performed catheter care while wearing gloves but did not don a gown. CNA C also cleansed the groin, scrotum, and catheter tubing starting about 2 inches away from the insertion site and did not cleanse the urinary meatus or the catheter tubing at the insertion site. When asked, CNA C stated a gown was not needed and that the insertion site did not need to be cleaned. The ICP and ADON both stated that a gown should be worn and that the catheter insertion site should be cleansed. Resident #158 was admitted with diagnoses including diabetes, bacteremia, and pyonephrosis and had a BIMS score of 12. The physician ordered contact isolation for Enterobacter cloacae. During observation, CNA A entered the resident’s room without PPE and later stated she was not aware the resident was on contact precautions; she also stated a gown, gloves, and mask should have been worn. CNA B also entered the resident’s room without PPE while carrying a food tray and later stated she should have put PPE on before entering. The DON stated that staff should follow whatever PPE was listed on the contact precautions sign.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that call lights were within reach for a resident, leading to a deficiency in accommodating the needs and preferences of the resident. The facility's policy, revised on January 4, 2023, mandates that call lights should be positioned within reach of residents while they are in bed or other sleeping accommodations. However, during an observation on August 19, 2024, it was noted that the call light for a resident with severe cognitive impairment and multiple medical conditions, including hemiplegia and hemiparesis, was found on the floor, out of the resident's reach. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that call lights should be within residents' reach. The resident in question had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment and required supervision to total assistance with activities of daily living. Despite these needs, the call light was not accessible, as confirmed by staff observations and interviews, highlighting a failure to adhere to the facility's policy and ensure resident safety and communication.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report allegations of abuse within the required 2-hour timeframe for two residents involved in an incident. According to the facility's policy, any alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, but not later than 2 hours after the allegation is made. However, the incident involving Resident #170 and Resident #270 occurred on 8/28/2023 at 4:48 PM, but the facility did not report it to the state agency until 8/29/2023 at 4:27 PM, which is beyond the stipulated timeframe. Resident #170, who had no cognitive impairment, reported that Resident #270 entered her room and hit her, swinging an open hand and scratching her face. Resident #270, who had severe cognitive impairment and was a wanderer, was confused and unable to provide details about the incident. Both residents were assessed with no visible injuries, and Resident #270 was sent for a psychiatric evaluation. Despite the facility's investigation and separation of the residents, the delay in reporting the incident to the state agency constitutes a deficiency in adhering to the facility's policy and regulatory requirements.
Failure to Complete Significant Change MDS Assessment for Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for a resident who was admitted to hospice care. According to the facility's policy and the Resident Assessment Instrument (RAI) Version 3.0 Manual, a Significant Change in Status Assessment (SCSA) must be completed when a resident experiences a significant change in condition, such as enrolling in hospice care. However, the medical record review revealed that no such assessment was completed for the resident, who was admitted to hospice care and had severe cognitive impairment as indicated by a Brief Interview of Mental Status (BIMS) score of 3. Interviews with the facility's MDS Licensed Practical Nurse (LPN) and MDS Registered Nurse (RN) confirmed that a Significant Change MDS assessment should have been performed and submitted when the resident was placed on hospice services. Despite this requirement, the assessment was not completed, and hospice care was not documented in the Quarterly MDS assessment. The hospice agency's Clinical Director also confirmed that the resident received hospice services at the facility, further highlighting the oversight in completing the necessary assessment.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise care plans for several residents, leading to deficiencies in care management. For Resident #18, the care plan was not updated to reflect the discontinuation of an antipsychotic medication, Quetiapine Fumarate, which was initially prescribed for depressive disorder. The Minimum Data Set (MDS) Coordinator acknowledged that the care plan should have been updated to reflect this change. Resident #111's care plan was not revised after the discontinuation of a Foley catheter, which was initially used for urine retention. The MDS Coordinator confirmed that the care plan should have been updated to reflect the removal of the catheter. Additionally, Residents #170 and #270 were involved in physical altercations, but their care plans were not updated to include interventions related to these incidents. The MDS Registered Nurse (RN) confirmed that the care plans should have been revised to reflect the altercations. Resident #175 experienced a fall, but the care plan was not updated to address this incident. The MDS Coordinator stated that ideally, an intervention should have been added to prevent further falls. Furthermore, Resident #273's care plan did not include a focus on hospice care, despite an order for hospice services being initiated. The MDS Licensed Practical Nurse (LPN) confirmed that the care plan did not address hospice services, indicating a failure to update the care plan accordingly.
Inadequate Incontinence Care During Meal Times
Penalty
Summary
The facility failed to provide adequate incontinence care for six residents, as evidenced by delayed response times to call lights, particularly during meal times. Residents reported waiting for extended periods, sometimes up to three hours, to receive assistance with toileting and incontinence care. This delay in care was corroborated by multiple residents who used clocks and personal devices to time the response intervals. The facility's policy mandates that residents receive necessary assistance with activities of daily living, including toileting, to maintain personal hygiene and dignity. Interviews with residents revealed that call light response times were notably poor during breakfast, lunch, and dinner, with some residents left in soiled conditions for prolonged periods. Residents expressed frustration and discomfort, with one resident describing an incident where they were left wet and dirty for three hours. Another resident recounted an experience of struggling to manage their incontinence care independently due to a lack of timely assistance, exacerbating their respiratory condition. Staff interviews indicated a misunderstanding or miscommunication regarding the prioritization of resident care during meal service. Some CNAs believed they were not allowed to change residents during meal tray delivery due to concerns about cross-contamination, while others stated they would seek help from colleagues. The facility's administrator acknowledged awareness of issues related to bathing but emphasized that residents should receive necessary care regardless of meal service activities.
Failure to Administer and Document CPAP Treatment
Penalty
Summary
The facility failed to follow the Medical Doctor's orders for a resident, leading to a deficiency in care. The resident, who was admitted with multiple diagnoses including Acute Respiratory Failure, Pneumonia, and Chronic Obstructive Pulmonary Disease, was prescribed the use of a CPAP device with oxygen while sleeping or napping. However, the Treatment Administration Record (TAR) showed no documentation of the administration of oxygen with CPAP on several specific dates for the dayshift. This lack of documentation indicates that the prescribed treatment was not administered as ordered. The facility's policy on medication administration requires that medications and treatments be documented immediately after administration. During an interview, the Director of Nursing confirmed the absence of documentation for the specified dates, acknowledging that the expectation is for nursing staff to sign off on treatments immediately after they are given. This failure to document and potentially administer the prescribed treatment represents a deviation from the facility's policies and the physician's orders, impacting the resident's care.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to implement an effective pain management regimen for a resident, identified as Resident #111, who was admitted with multiple diagnoses including Congestive Heart Failure, Type 2 Diabetes Mellitus, and Chronic Kidney Disease. The facility's policy required pain assessments upon admission, quarterly, and with any change in condition, ensuring pain management consistent with professional standards and the resident's goals and preferences. Despite this, Resident #111 experienced significant pain that interfered with functional activities and sleep, as noted in both Occupational Therapy (OT) and Physical Therapy (PT) evaluations. Resident #111's comprehensive care plan included opioid therapy for pain management, yet the Medication Administration Record (MAR) indicated that Tramadol, prescribed for moderate to severe pain, was not administered since admission. Instead, the resident received Tylenol on only two occasions, despite reporting severe pain levels. Interviews with the resident and staff revealed that the resident frequently experienced pain, particularly during movement and therapy sessions, which hindered his progress. The resident expressed that Tylenol was insufficient for pain relief, and therapy staff noted that pain management was not effectively communicated or coordinated with nursing staff. Interviews with facility staff, including a CNA, PT, LPN, and the Director of Nursing (DON), highlighted a lack of communication and coordination regarding the resident's pain management needs. The PT reported ongoing issues with pain management affecting therapy sessions and noted that pain medication was only given when requested by the resident. The DON and LPN acknowledged the need for better pain management and communication, with the LPN unaware of the resident's pain concerns raised during a care plan meeting. The facility's administrator expected therapists to escalate pain management issues if not addressed by nursing staff.
Deficiency in Pharmaceutical Services and Medication Tracking
Penalty
Summary
The facility failed to provide adequate pharmaceutical services policies and procedures to ensure the proper dispensing and disposition of physician-ordered medications for a resident. The facility's policy required that medications brought in by a resident or responsible party must be verified by a nurse and meet specific guidelines. However, there was no documentation of receipt, verification, or disposition of medications brought in by a family member for a resident who was admitted with multiple diagnoses, including cirrhosis and acute kidney failure. The resident's medical records and medication administration records showed that the medication rifaximin was ordered but not administered as per the physician's order. Additionally, there was no documentation of the medication being returned to the pharmacy or disposed of properly after the resident was discharged to the hospital. Interviews with nursing staff revealed that there was no procedure or form to document the receipt or disposition of medications brought from home, and the pharmacy representative confirmed that personal medications not dispensed by the pharmacy would be returned to the facility without a chain of custody. Family members reported bringing the medication to the facility as requested but were unable to retrieve it after the resident's discharge. The facility administrator and medical director acknowledged the lack of a policy or procedure for tracking medications brought into the facility by family members, indicating a gap in the facility's pharmaceutical services and documentation processes.
Deficiency in Resident Call System Maintenance
Penalty
Summary
The facility failed to maintain a functional resident call system for a resident, as required by their policy. The policy, revised on January 4, 2023, mandates that the call system should be accessible to residents from their beds or other sleeping accommodations and that any malfunctions should be reported immediately to the Director of Maintenance. During an observation on August 20, 2024, it was found that the call light in the resident's room was missing a cord, rendering it unusable. A Licensed Practical Nurse (LPN) noted the call light was on the floor and possibly broken. A Certified Nursing Assistant (CNA) later discovered the call light cord on the floor with exposed wires. The Maintenance Director, upon being informed, stated they were unaware of the broken call light.
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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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How nearby facilities compare on the same public inspection record.
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| Antioch Tn Opco, Llc | 3.6 mi | ★★★★★ | 3 | 3 |
| Smyrna Care Center | 5.7 mi | ★★★★★ | 1 | 1 |
| The Waters Of Smyrna, Llc | 5.9 mi | ★★★★★ | 0 | 0 |
| Bethany Center For Rehabilitation And Healing Llc | 7.3 mi | ★★★★★ | 0 | 0 |
| Somerfield At The Heritage | 11.3 mi | ★★★★★ | 0 | 0 |
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