Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Johnson County Health And Rehab, Llc during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and substantial to maximum transfer needs was care planned and ordered for a mechanical lift for all transfers. Two MA-Cs attempted a two-person transfer without reviewing the Closet Care Plan, without using the lift, and without a gait belt; the resident could not assist, the legs gave out, and the resident was lowered to the floor. The resident reported soreness but no injuries, and interviews confirmed the resident was too weak to stand and that staff had not followed the current transfer instructions.
A resident with severe cognitive impairment and a known risk for wandering exited the facility unsupervised after an alarm was triggered. An office aide turned off the alarm without notifying staff or initiating a resident count, contrary to policy. The resident was later found over a mile away, exhausted, after staff realized the individual was missing.
The facility failed to ensure that residents on the secure unit were fed with dignity, as multiple CNAs were observed standing while providing feeding assistance. Staff interviews confirmed awareness of proper feeding protocols, but cited challenges due to the high number of residents.
The facility failed to maintain a medication error rate of less than 5% for a resident with Gout and GERD. An LPN administered incorrect dosages of Simethicone and Tart Cherry Advanced, resulting in a medication error rate of 6.67%. The DON confirmed the correct orders, and the facility's Medication Administration policy lacked pertinent information.
The facility failed to ensure medications on two medication carts were properly labeled with open dates. Observations revealed open bottles of eye drops and an inhaler without open dates, despite specific discard instructions. The DON confirmed the lack of adherence to these instructions.
The facility failed to ensure food items were sealed or covered during meal preparation and did not properly clean, rinse, and sanitize equipment, potentially affecting 104 residents. Observations included uncovered food items and improper cleaning of a food processor, with staff acknowledging the need for better food handling and sanitation practices.
Failure to Follow Mechanical Lift Transfer Plan
Penalty
Summary
The facility failed to ensure staff followed a care-planned intervention during a transfer for one resident who had been admitted with acute and chronic respiratory failure, lung disease, a urinary tract infection, and skin and subcutaneous tissue disorders. The resident’s MDS showed moderate cognitive impairment and substantial to maximum assistance was needed for transfers. The care plan, initiated after admission, required a mechanical lift for all transfers, and physician orders also directed use of a mechanical lift for all transfers. On the day of the incident, two MA-Cs went to obtain the resident’s weight and transferred the resident without reading the Care Plan or using the mechanical lift. The resident was unable to help with the transfer, and the staff attempted a two-person assist without a gait belt. When the resident’s legs gave out, the staff lowered the resident to the floor. The incident report stated the resident did not sustain injuries, and vital signs were obtained. The resident’s family and APRN were notified. Interviews and progress notes confirmed that the MA-Cs did not review the Closet Care Plan before the transfer and relied on prior transfer methods instead of the current mechanical-lift requirement. The resident stated they had been transferred without the mechanical lift and fell, reporting soreness but no injuries. The PT stated the resident did not have the strength and was too weak to stand at that time. The DON, MDS Coordinator, and Administrator all stated that staff should review the Closet Care Plan before providing care, and the MDS Coordinator confirmed the resident had been changed to a mechanical lift for all transfers.
Failure to Prevent Elopement Due to Inadequate Alarm Response
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, and a history of wandering eloped from the facility. The resident was admitted with diagnoses including dementia and psychotic disorder, and had a documented high risk for elopement, as indicated by care plans and risk assessments. On the day of the incident, the resident exited the facility through the front door by pressing the release bar, which triggered an alarm. Video evidence showed the resident leaving the building unsupervised. Following the alarm, an office aide responded by turning off the alarm and glancing out the front door but did not notify any other staff members or the nursing team about the alarm. The office aide then returned to her desk and answered a phone call, failing to initiate a resident count or alert the charge nurse, DON, or Administrator as required by facility policy. Other staff members, including CNAs and housekeepers, were unaware of the resident's exit until later, and initial assumptions were made that the resident was elsewhere in the facility or outside for a routine activity such as smoking. The resident was eventually discovered missing after a CNA noticed the resident's breakfast tray was untouched and began searching. A Code Green was called, and the resident was found by a CNA supervisor at a park approximately 1.25 miles from the facility, appearing exhausted. Interviews confirmed that the facility's elopement policy, which required immediate reporting and resident accounting when an alarm sounded, was not followed. The failure to respond appropriately to the alarm and to notify staff resulted in the resident being unsupervised outside the facility for an extended period.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to ensure that residents on the secure unit were fed in a manner that provided dignity. Observations revealed that multiple CNAs were standing while providing feeding assistance to residents, which is not in line with maintaining the residents' dignity. Specifically, CNA #2, CNA #3, and CNA #1 were all observed standing while feeding residents at different times. Interviews with the CNAs and an LPN confirmed that the staff were aware that feeding should be done at eye level, but cited the high number of residents as a challenge. The facility's document on Residents Rights emphasizes the right to be treated with consideration, respect, and full recognition of dignity and individuality, which was not upheld in these instances.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5% for one resident observed during medication administration. Specifically, two errors were observed in the administration of medications to Resident #9, resulting in a medication error rate of 6.67%. Resident #9, who has diagnoses of Gout and Gastro-esophageal reflux disease (GERD), was supposed to receive 2 capsules of Simethicone 180 mg four times a day and 1000 mg of Tart Cherry Advanced twice a day. However, the Licensed Practical Nurse (LPN) administered only 1 capsule of Simethicone and 1 tablet of Tart Cherry Advanced, which did not meet the prescribed dosage. The deficiency was confirmed through observations and interviews. The LPN admitted to administering the incorrect dosages when questioned by the surveyor. The Director of Nursing (DON) also confirmed the correct orders for the medications. The facility's Medication Administration policy, reviewed by the surveyor, did not contain pertinent information related to the deficiency. This oversight in medication administration led to a medication error rate exceeding the acceptable threshold of 5%.
Failure to Properly Label and Discard Medications
Penalty
Summary
The facility failed to ensure that medications on two of the six medication carts assessed were properly labeled with an open date. Specifically, on the 300 Hall medication cart, an open bottle of eye drops was observed without an open date, despite being received from the pharmacy on 02/28/2024. Similarly, on the 600 Hall medication cart, an open bottle of eye drops, an open inhaler, and a second open bottle of eye drops were all found without open dates, even though they were received from the pharmacy on 02/09/2024 and 02/22/2024, respectively. Registered Nurse (RN) #4 confirmed the absence of open dates on these medications during the surveyor's observation. The Director of Nursing (DON) acknowledged that medications should have an open date written on them when they are first used. The DON confirmed the lack of open dates on the medications and provided package inserts for the identified medications, which included specific discard instructions that had not been followed. For example, the Olopatadine Ophthalmic Solution should be discarded 4 weeks after opening, the inhaler should be thrown away 3 months after being removed from the foil pouch, and the Latanoprost Ophthalmic solution should be stored at room temperature for up to 6 weeks once opened. The DON confirmed that these discard instructions were not adhered to, leading to the deficiency noted in the report.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food items were sealed or covered during meal preparation and did not properly clean, rinse, and sanitize equipment, which could lead to potential foodborne illness for the 104 residents receiving meals from the kitchen. Observations included a dietary aid using a food processor to puree chili and then placing the food processor into a sink with other dirty utensils. The food processor was hand-washed with dishwashing liquid, but soap residue remained, and it was not sanitized before being used again to process green beans. Additionally, various food items, including apple slices, vegetable soup, and biscuits, were observed uncovered and not contained during meal preparation, increasing the risk of contamination. Interviews with dietary staff revealed a lack of adherence to proper food handling and sanitation procedures. Dietary Aid #2 acknowledged that food should be covered to prevent contamination and maintain temperature, while the Dietary Manager confirmed that equipment should be cleaned, rinsed, and sanitized to prevent cross-contamination and soap residue in food. The Dietary Manager also recommended that food be covered during meal preparation to prevent contamination from flies or other sources. These practices were not followed, leading to the identified deficiencies in food safety and sanitation.
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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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Nursing homes near Clarksville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Russellville Nursing And Rehabilitation Center | 19.4 mi | ★★★★★ | 8 | 0 |
| Stella Manor Nursing And Rehabilitation Center | 20.4 mi | ★★★★★ | 0 | 0 |
| Paris Health And Rehabilitation Center | 20.6 mi | ★★★★★ | 7 | 0 |
| Legacy Heights Nursing And Rehab, Llc | 21.6 mi | ★★★★★ | 0 | 0 |
| Ozark Nursing And Rehab | 22.4 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.