Deficiencies (last 4 years)
Deficiencies (over 4 years)
8.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
93% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
78% occupied
Based on a November 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 112
Deficiencies: 3
Date: Nov 19, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including resident assessments, food safety and sanitation, and infection prevention and control.
Findings
The facility failed to ensure timely completion and signing of resident assessments for 3 of 23 sampled residents, maintain a clean and sanitary kitchen environment, and ensure staff adherence to infection control practices including proper use of personal protective equipment during catheter care for 2 residents.
Deficiencies (3)
Failed to ensure assessments were signed to reflect timely submission and failed to complete quarterly assessments timely for 3 of 23 sampled residents.
Failed to maintain a clean and sanitary kitchen environment with food debris, oil drippings, and black dried liquid substances observed in multiple kitchen areas.
Failed to ensure infection control practices to prevent spread of communicable diseases when 3 staff failed to don PPE and properly perform urinary catheter care for 2 sampled residents.
Report Facts
Residents affected: 3
Residents affected: 112
Residents receiving meal trays: 111
Staff involved: 3
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nursing Assistant | Failed to don gown and properly perform urinary catheter care for Resident #135 |
| CNA A | Certified Nursing Assistant | Entered Resident #158's room without donning PPE |
| CNA B | Certified Nursing Assistant | Entered Resident #158's room without donning PPE with a food tray |
| Dietary Director | Dietary Director | Interviewed regarding kitchen sanitation issues |
| Infection Control Preventionist | Infection Control Preventionist | Interviewed regarding PPE use and catheter care |
| Assistant Director of Nursing A | Assistant Director of Nursing | Interviewed regarding catheter care and PPE use |
| Director of Nursing | Director of Nursing | Interviewed regarding PPE use for contact precautions |
Inspection Report
Routine
Deficiencies: 9
Date: Aug 23, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, abuse reporting, assessment, care planning, medication administration, pain management, call system functionality, and pharmaceutical services at Life Care Center of Hickory Woods.
Findings
The facility was found deficient in multiple areas including failure to ensure call lights were within reach, timely reporting of abuse allegations, completion of significant change assessments for hospice residents, revision of care plans after incidents or changes, provision of incontinence care, adherence to physician orders for treatments and medications, effective pain management, proper pharmaceutical services policies for medications brought from home, and maintenance of a working call system in resident bathrooms.
Deficiencies (9)
Failed to ensure call lights were within reach for 1 of 118 residents.
Failed to timely report allegations of abuse within 2 hours for 2 of 3 residents reviewed.
Failed to complete a Significant Change Minimum Data Set (MDS) assessment for 1 of 4 residents reviewed.
Failed to revise care plans for multiple residents after incidents or changes in condition.
Failed to provide incontinence care for 6 of 31 residents reviewed.
Failed to follow Medical Doctor's orders for 1 of 9 residents reviewed.
Failed to implement an effective pain management regimen for 1 of 6 residents reviewed.
Failed to provide pharmaceutical services policies and procedures ensuring proper handling of medications brought from home for 1 resident.
Failed to maintain a working call system in resident bathroom for 1 resident.
Report Facts
Residents reviewed for call light access: 118
Residents reviewed for abuse reporting: 3
Residents reviewed for significant change assessment: 4
Residents reviewed for care plan revision: 6
Residents reviewed for incontinence care: 31
Residents reviewed for medication adherence: 9
Residents reviewed for pain management: 6
Residents reviewed for pharmaceutical services: 1
Residents reviewed for call system functionality: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN G | Licensed Practical Nurse | Confirmed call light was not within Resident #82's reach. |
| LPN J | 100 Hall Unit Manager | Confirmed call lights should be within residents' reach. |
| Director of Nursing | Director of Nursing (DON) | Confirmed call lights should be within residents' reach; confirmed missing documentation of oxygen with CPAP administration; commented on pain management expectations. |
| CNA M | Certified Nursing Assistant | Witnessed resident report of abuse. |
| Family Member R | Reported witnessing resident altercation. | |
| Administrator | Facility Administrator | Could not provide documentation of timely abuse reporting; stated no policy for tracking medications brought from home. |
| MDS LPN TT | Licensed Practical Nurse | Confirmed no Significant Change MDS assessment for hospice resident. |
| MDS RN P | Registered Nurse | Confirmed no Significant Change MDS assessment for hospice resident; confirmed care plans not updated after resident altercations. |
| RN WW | Clinical Director | Confirmed hospice services provided to Resident #273. |
| CNA PP | Certified Nursing Assistant | Reported pain experienced by Resident #111. |
| PT BB | Physical Therapist | Reported pain limits therapy for Resident #111; communicated pain concerns to nursing. |
| LPN D | Licensed Practical Nurse | Discussed pain management and medication administration for Resident #111; described medication handling procedures. |
| CNA BBB | Certified Nursing Assistant | Stated residents cannot be changed during mealtimes due to cross contamination. |
| Maintenance Director | Maintenance Director | Was unaware of broken call light in Resident #105's bathroom. |
| Pharmacy Representative | Described pharmacy policy on medications brought from home and returns. | |
| Family Member OO | Reported bringing medication to facility and not receiving it back after discharge. | |
| RN H | Registered Nurse | Reported medication brought from home was picked up by family after discharge. |
Inspection Report
Routine
Census: 118
Deficiencies: 9
Date: Aug 23, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, abuse reporting, assessment, care planning, medication administration, pain management, and call system functionality.
Findings
The facility was found deficient in multiple areas including failure to ensure call lights were within reach for residents, timely reporting of abuse allegations, completion of significant change assessments for hospice residents, revision of care plans after incidents or changes, provision of incontinence care, adherence to physician orders for treatments and medications, effective pain management, pharmaceutical services policies for medications brought from home, and maintenance of resident call systems.
Deficiencies (9)
Failed to ensure call lights were within reach for 1 of 118 residents.
Failed to timely report allegations of abuse within 2 hours for 2 of 3 residents reviewed.
Failed to complete a Significant Change Minimum Data Set (MDS) assessment for 1 of 4 residents reviewed.
Failed to revise care plans for multiple residents after incidents or changes in condition.
Failed to provide incontinence care for 6 of 31 residents reviewed.
Failed to follow Medical Doctor's orders for 1 of 9 residents reviewed, including lack of documentation of oxygen with CPAP administration.
Failed to implement effective pain management for 1 of 6 residents reviewed.
Failed to provide pharmaceutical services policies and procedures ensuring proper handling of medications brought from home for 1 resident.
Failed to maintain a working call system in resident's bathroom and bathing area for 1 of 31 residents reviewed.
Report Facts
Residents reviewed for call light access: 118
Residents reviewed for abuse reporting: 3
Residents reviewed for significant change assessment: 4
Residents reviewed for care plan revision: 6
Residents reviewed for incontinence care: 31
Residents reviewed for medication adherence: 9
Residents reviewed for pain management: 6
Residents reviewed for pharmaceutical services: 1
Residents reviewed for call system maintenance: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN G | Licensed Practical Nurse | Confirmed call light was not within Resident #82's reach |
| LPN J | 100 Hall Unit Manager | Confirmed call lights should be within residents' reach |
| Director of Nursing | Director of Nursing | Confirmed call lights should be within residents' reach and confirmed lack of documentation for oxygen with CPAP administration and pain management |
| CNA M | Certified Nursing Assistant | Witnessed resident report of abuse |
| Family Member R | Reported witnessing resident altercation | |
| Administrator | Administrator | Confirmed abuse reporting requirements and lack of documentation |
| RN SS | Registered Nurse | Confirmed hospice services for Resident #273 |
| MDS LPN TT | Licensed Practical Nurse | Confirmed no Significant Change MDS assessment submitted for hospice services |
| MDS RN P | Registered Nurse | Confirmed no Significant Change MDS assessment submitted for hospice services |
| RN WW | Clinical Director | Confirmed hospice services for Resident #273 |
| MDS Coordinator | Confirmed care plan deficiencies for multiple residents | |
| MDS RN P | Registered Nurse | Confirmed care plan not updated after resident-to-resident altercations |
| RN LLL | Registered Nurse | Reported witnessing resident fall and uncertainty about care plan update |
| CNA PP | Certified Nursing Assistant | Reported pain experienced by Resident #111 |
| PT BB | Physical Therapist | Reported pain limiting therapy for Resident #111 |
| LPN D | Licensed Practical Nurse | Reported pain complaints from Resident #111 and lack of notification about pain management plan |
| Pharmacy Representative | Described pharmacy policy on medications brought from home | |
| Family Member OO | Reported bringing medication to facility and not receiving it back after discharge | |
| RN H | Registered Nurse | Reported medication brought from home was picked up by family after discharge |
| CNA BBB | Certified Nursing Assistant | Reported inability to change residents during mealtimes due to cross contamination |
| Maintenance Director | Maintenance Director | Unaware of broken call light in Resident #105's room |
Inspection Report
Enforcement
Census: 10
Deficiencies: 2
Date: Dec 20, 2023
Visit Reason
The inspection visits on December 20, 2023, and February 21, 2024, were conducted due to the facility's failure to adopt a written fire control plan as required by regulations.
Findings
The facility was cited twice for failure to adopt a written fire control plan. Fire drills conducted showed delays in evacuation and staff noncompliance with the facility's evacuation policy.
Deficiencies (2)
Tenn. Comp. R. and Reg. 0720-26-.10(2)(c) requires an ACLF to adopt a written fire control plan. The facility failed to adopt such a plan in December 2023 and February 2024.
During the December 20, 2023 fire drill, staff failed to respond appropriately to the fire alarm and did not comply with the facility's written evacuation policy.
Report Facts
Residents present during fire drill: 10
Civil Monetary Penalty: 3000
Civil Monetary Penalty: 1000
Total Civil Monetary Penalty: 4000
Evacuation time: 13
Evacuation time: 14
Evacuation time: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rick Lucas | Executive Director | Authorized representative of the facility who signed the consent order. |
| Vishan J. Ramcharan | Associate General Counsel | Legal counsel for the Health Facilities Commission involved in the consent order. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 15, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to assess and provide timely treatment for a pressure ulcer and suspected deep tissue injury for one sampled resident.
Complaint Details
The complaint investigation found that the facility failed to assess and provide timely treatment for a pressure ulcer and deep tissue injury for Resident #2. The deficiency was substantiated with evidence of delayed physician orders and incomplete wound assessments.
Findings
The facility failed to timely identify and treat a stage 2 pressure ulcer and a deep tissue injury for Resident #2. Documentation showed delays in obtaining physician orders for wound care treatment, and nursing staff did not stage pressure ulcers as required. Interviews confirmed gaps in wound assessment and order acquisition processes.
Deficiencies (1)
Failure to assess and provide timely treatment for a pressure ulcer and suspected deep tissue injury for Resident #2.
Report Facts
Measurement of pressure ulcer: 2.5
Measurement of pressure ulcer: 4.5
Measurement of pressure ulcer: 0.2
Measurement of deep tissue injury: 2.3
Measurement of deep tissue injury: 2.3
Brief Interview for Mental Status (BIMS) score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Stated nurses assessed skin and documented pressure ulcers but did not stage them |
| Director of Nursing | Director of Nursing | Stated nurses were to identify and assess pressure ulcers and obtain orders for treatments |
| Wound Care Nurse | Wound Care Nurse | Described wound assessment and order process, confirmed delays in wound care orders |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 7, 2023
Visit Reason
A complaint survey of The Bridge At Hickory Woods Assisted Care Living Facility was conducted on February 7, 2023, resulting in findings of deficiencies.
Complaint Details
The complaint survey was substantiated with findings that the facility administered wrong medications to Resident #2 and failed to document the error or notify the resident's family until after the survey was in progress. Resident #2 did not suffer harm.
Findings
The facility failed to provide protective care by accidentally administering the wrong medications to one resident and failed to properly document the medication administration error or follow proper procedures after the error occurred.
Deficiencies (2)
Tenn. Comp. R. and Reg. 0720-26-.07(7)(a)1: The facility failed to provide protective care to a resident by administering the wrong medications.
Tenn. Comp. R. and Reg. 0720-26-.12(3)(e): The facility failed to properly document the medication administration error and did not follow procedures after the error occurred.
Report Facts
Civil Monetary Penalty: 1000
Civil Monetary Penalty: 1000
Days for Payment: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vishan J. Ramcharan | Associate General Counsel | Signed the consent order as legal counsel for the Health Facilities Commission. |
Inspection Report
Enforcement
Deficiencies: 1
Date: Dec 17, 2019
Visit Reason
This document is a Consent Order following a life safety survey conducted in December 2019 at The Bridge at Hickory Woods assisted-care living facility. The order addresses violations found during the survey related to fire drill evacuation times.
Findings
The life safety survey revealed that six residents failed to evacuate within thirteen minutes during a fire drill. The facility violated Rule 1200-08-25-.08(8) by retaining residents who could not evacuate within the required time.
Deficiencies (1)
Rule 1200-08-25-.08(8) was violated as the facility retained residents who could not evacuate within thirteen minutes during a fire drill. Six residents failed to evacuate within the required time.
Report Facts
Residents unable to evacuate within 13 minutes: 6
Civil monetary penalty: 1000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Elizabeth Heatwole | Administrator | Signed the Consent Order as the facility administrator. |
| Caroline R. Tippens | Senior Associate General Counsel | Signed the Consent Order on behalf of the Tennessee Department of Health. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 11, 2019
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide a duration for the use of a PRN psychotropic medication for one resident.
Complaint Details
The visit was complaint-related concerning the lack of a stop date for a PRN psychotropic medication order. The deficiency was substantiated based on medical record review and staff interviews.
Findings
The facility failed to provide a stop date or duration for the PRN order of clonazepam for Resident #14, which is against facility policy and regulatory requirements limiting PRN psychotropic medication orders to 14 days unless properly documented. Interviews with nursing staff and the Director of Nursing confirmed the omission.
Deficiencies (1)
Failure to provide a duration/stop date for the PRN psychotropic medication clonazepam for Resident #14.
Report Facts
Residents reviewed for unnecessary medications: 16
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Interviewed and confirmed no duration/stop date for Resident #14's PRN medication. | |
| Nurse Practitioner | Interviewed and confirmed writing the order without a stop date and awareness of the 14-day regulation. | |
| Director of Nursing | Interviewed and confirmed no stop date for the PRN medication and acknowledged the oversight. |
Inspection Report
Enforcement
Census: 77
Deficiencies: 6
Date: Jun 5, 2019
Visit Reason
This document is a Consent Order resulting from an enforcement action by the Tennessee Board for Licensing Health Care Facilities concerning The Bridge at Hickory Woods following a health and life safety survey conducted in August 2018.
Findings
The facility failed to repair or replace recalled PTAC units, ensure sufficient staff during emergency evacuation, follow fire control plans, and safely evacuate residents in a timely manner during a fire incident. A Plan of Correction was submitted and verified as completed by September 25, 2018.
Deficiencies (6)
Rule 1200-08-25-.06(1)(b)(3) Life Safety: The facility failed to develop and adhere to written policies and procedures as required by regulations.
Rule 1200-08-25-.07(7)(a)(2) Services Provided: The facility failed to provide personal services ensuring resident safety.
Rule 1200-08-25-.08(8) Admissions, Discharges, and Transfers: The facility violated provisions related to resident admissions and transfers.
Rule 1200-08-25-.09(1) Building Standards: The facility failed to maintain the physical plant and environment to assure resident safety and well-being.
Rule 1200-08-25-.09(5) Building Standards: The facility made major alterations without prior approval from the department.
Rule 1200-08-25-.10(2)(a) and (c) Life Safety: The facility failed to eliminate fire hazards and adopt a written fire control plan.
Report Facts
Residents present: 77
Residents ambulatory with walker: 35
Residents ambulatory with wheelchair: 20
Staff providing care: 4
Civil monetary penalty: 3000
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