Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Signature Healthcare Of Clarksville during CMS and state inspections, most recent first.
Multiple residents with cognitive and mobility impairments experienced repeated falls due to inadequate supervision, incomplete fall investigations, and failure to implement or maintain safety interventions. One resident suffered serious injuries, including a subdural hemorrhage and fractures, after several unwitnessed falls. Neuro checks and vital sign monitoring were not consistently performed or documented according to facility policy, and required interventions such as fall mats were not always in place. Staff interviews confirmed lapses in following fall protocols and documentation.
A resident with significant physical impairments and dependence on staff for ADL care was observed with severely matted and oily hair, having received hair washing only once since admission. Despite requests from the resident and her family for assistance with hair grooming and cutting, staff did not provide necessary care, citing lack of equipment and scope of practice limitations. Facility staff confirmed that hair care was not being performed, contrary to policy requirements for maintaining resident dignity.
The facility did not provide required notifications to the families or representatives of two residents when their trust fund account balances exceeded the Medicaid eligibility limit. Both residents had cognitive impairments, and there was no documentation that the mandated notification letters were received, despite account balances being well above the allowable threshold.
The facility failed to report suspected abuse and injuries of unknown origin for two residents. In one case, a resident with cognitive and mobility impairments developed a bruise and fracture of unknown source, which was not reported to the state agency despite policy requirements. In another case, a resident with severe cognitive impairment was struck by a visitor, but the incident was not reported as abuse because the resident denied feeling harmed, even though staff witnessed the event. These failures reflect noncompliance with mandatory reporting and investigation protocols.
A resident with multiple medical conditions, including heart failure and dementia, was ordered to receive oxygen via nasal cannula at 2 L/min PRN. Despite this, observations showed the oxygen concentrator was set above the prescribed rate on multiple occasions. The DON confirmed the flow rate did not match the physician's order, indicating staff did not follow the prescribed oxygen administration.
Two nurses failed to follow infection control practices by not sanitizing reusable equipment, such as a stethoscope, syringe, and blood pressure cuff, after use during medication administration for two residents with complex medical conditions. Both nurses acknowledged that the equipment should have been cleaned, and the facility's policy required proper cleaning and reprocessing of such items.
Failure to Prevent Falls and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure a safe and secure environment for multiple residents at risk for falls and accidents, as evidenced by inadequate supervision, incomplete fall investigations, and failure to implement or maintain appropriate interventions. Several residents with cognitive impairments and mobility issues experienced repeated falls, with one resident sustaining multiple serious injuries including a subdural hemorrhage, cervical fracture, and bilateral rib fractures after a series of unwitnessed and unassisted falls. The facility did not consistently conduct thorough fall investigations to identify all contributing factors or root causes, and did not always update or implement individualized care plan interventions following each incident. Documentation revealed that neuro checks and vital signs were not completed according to the facility's own neuro check guidelines after unwitnessed falls or falls with potential head injury. In several cases, neuro checks were either not initiated, not performed at the required intervals, or not documented at all. Additionally, witness statements were not always obtained, and fall interventions such as fall mats were not consistently present in resident rooms despite being listed in care plans. Staff interviews confirmed that some interventions were not in place and that there was confusion or lack of adherence to fall investigation and documentation protocols. The facility's failure to provide adequate supervision and maintain an environment free from accident hazards resulted in Immediate Jeopardy for at least one resident, who was highly vulnerable due to severe cognitive impairment and mobility issues. The lack of timely and thorough investigations, incomplete documentation, and failure to implement or maintain appropriate safety interventions contributed to repeated falls and serious injuries among residents. These deficiencies were identified through policy review, medical record review, observation, and staff interviews during the survey.
Failure to Provide Dignified Hair Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate care and services to promote dignity for a resident who required assistance with activities of daily living (ADL), specifically in the area of hair care. The resident, who was admitted with multiple diagnoses including paraplegia, spina bifida, and pressure ulcers, was dependent on staff for personal hygiene and grooming. Observations revealed that the resident's hair was matted and oily, and the resident reported only having her hair washed once since admission. She also stated that she and her mother had requested staff to cut the matted hair, but the DON informed them that it was not within her scope of practice and that the facility lacked the necessary equipment or personnel to cut hair. Interviews with staff confirmed that hair grooming and washing were part of the resident's ADL care, but these tasks were not being performed due to the condition of the hair. The DON and a CNA acknowledged the resident's hair was severely matted and had not been maintained. The administrator confirmed responsibility for ensuring residents' dignity and rights but did not indicate that appropriate hair care had been provided. Facility policy requires all residents to be treated with respect and dignity, including assistance with personal care, but this was not upheld in this instance.
Failure to Notify When Resident Trust Fund Balances Exceeded Limits
Penalty
Summary
The facility failed to notify the family and/or resident when the amount in the residents' trust fund accounts exceeded the eligibility limit, as required by both facility policy and federal regulations. Specifically, for two residents, account balances were found to be significantly above the $2,000 limit for Medicaid eligibility, with one account showing balances of $4,180.09 and $4,375.49 over two quarters, and another showing $6,085.51 and $6,283.72 over the same periods. The facility's policy mandates that when a resident's account is within $200 of the permitted limit, a notification letter must be sent to the resident or their legal representative, and documentation of this notification must be maintained in the financial folder. Review of the records revealed that while the Business Office Manager stated that the families had been sent the required $200 notification letters, there was no documentation provided to confirm that the families of the two residents had actually received these letters. Both residents had cognitive impairments, with one having severe cognitive impairment and the other moderate impairment, further emphasizing the importance of proper notification to their representatives. The lack of documentation and failure to ensure notification constitutes a deficiency in the facility's management of resident trust funds.
Failure to Report Suspected Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report alleged violations involving abuse and injury of unknown source for two residents, as required by both facility policy and federal and state law. For one resident with significant cognitive and physical impairments, a bruise and subsequent fracture of unknown origin were discovered after the resident had been discharged to the hospital. Multiple staff members and the resident's family observed the injury, but there was no clear documentation of how or when the injury occurred. Despite the facility's policy requiring immediate investigation and reporting of injuries of unknown source, the incident was not reported to the state agency, and the Director of Nursing and Administrator were uncertain about whether the injury had been reported at all. In the second case, a resident with severe cognitive impairment was struck on the chest by a visitor during an altercation witnessed by the facility's social worker. The social worker intervened and reported the incident to the Administrator and DON, but did not consider the event to be physical abuse and did not report it to the state agency. The care plan was updated to reflect the resident's family relationship dynamics, but there was no evidence of further action or restriction of visitation. The Administrator later stated that the incident was not reported because the resident denied feeling abused, despite the resident's documented severe cognitive impairment. Both incidents demonstrate a failure to follow facility policy and regulatory requirements for reporting suspected abuse, neglect, or injuries of unknown origin. The facility did not ensure that all alleged violations were promptly investigated and reported to the appropriate authorities, as required. Staff interviews revealed confusion and lack of clarity regarding reporting responsibilities, and documentation was inconsistent or incomplete regarding the injuries and the actions taken.
Failure to Follow Physician's Orders for Oxygen Administration
Penalty
Summary
The facility failed to follow physician's orders for oxygen administration for one resident. According to facility policy, oxygen therapy must be administered as ordered by a physician, and licensed nurses are expected to follow these orders. Medical record review showed that the resident, who had diagnoses including anemia, heart failure, dementia, and anxiety disorder, was admitted with a physician's order for oxygen via nasal cannula at 2 liters per minute as needed. The Medication Administration Record indicated that oxygen was administered daily at the ordered rate. However, observations on two separate occasions revealed that the resident was receiving oxygen at higher flow rates than prescribed, with the concentrator set at 3 liters per minute and later at 2.5 liters per minute. During an interview, the DON confirmed that the oxygen flow rate was not set according to the physician's order and acknowledged that staff should have followed the prescribed rate. This discrepancy between the physician's order and the actual administration of oxygen constituted a failure to provide safe and appropriate respiratory care as required by facility policy.
Failure to Sanitize Reusable Equipment During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices were followed during medication administration for two residents. In one instance, a nurse used a stethoscope to check a resident's feeding tube placement and then returned the stethoscope to her neck without cleaning it. The same nurse administered medication via a feeding tube and, after use, placed the syringe back in its package and hung it on a pole without rinsing or cleaning it. The nurse later confirmed that the stethoscope should have been cleaned after use, and the Director of Nursing also confirmed that syringes should be cleansed after medication administration. In another instance, a nurse checked a resident's blood pressure using an automatic wrist cuff, placed the cuff in her lab coat pocket after use, and later placed it on top of the medication cart without cleaning it. When questioned, the nurse acknowledged that the wrist cuff should have been cleansed after use. Both residents involved had significant medical histories, including conditions such as cerebral palsy, gastrostomy, MRSA, seizures, COPD, diabetes, and allergic rhinitis. The facility's infection control policy required the cleaning and reprocessing of reusable resident-care equipment, which was not followed in these observed cases.
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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) |
|---|---|---|---|---|
| Spring Meadows Health And Rehabilitation | 2.5 mi | ★★★★★ | 0 | 0 |
| Ahava Healthcare Of Clarksville | 4.6 mi | ★★★★★ | 7 | 0 |
| Park Meadows Post Acute | 5.9 mi | ★★★★★ | 0 | 0 |
| Brigadier General Wendell H Gilbert Tn State Veter | 12.1 mi | ★★★★★ | 1 | 0 |
| Hillcrest Healthcare Center | 17.4 mi | ★★★★★ | 13 | 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.