Average — CMS composite of the measures below.
The next survey window likely opens 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 Clarksville Nursing Home during CMS and state inspections, most recent first.
The facility failed to ensure that communal shower water temperatures were consistently comfortable and adequately monitored, resulting in fluctuating and often low temperatures in two of three shower rooms. Several cognitively intact male residents who were independent or needed limited assistance with bathing reported that shower water was either hot or cold, did not stay warm for the entire shower, or was only warm and not as hot as desired, despite appearing clean and appropriately groomed. Direct observations showed shower temperatures on two halls ranging from 85°F to just over 105°F, with rapid drops below 100°F after initially warming. CNAs and an LVN reported few or no complaints and relied on informal adjustments rather than systematic checks, while the Maintenance Director acknowledged he did not routinely measure or document shower temperatures, was unaware of the inadequate temperatures, and noted equipment issues such as a nonfunctioning circulator and recent water heater replacement. The DON stated she did not monitor shower temperatures and had not received complaints, and the Administrator was unaware that temperatures were not being monitored, with no facility policy in place for shower water temperatures despite state and federal guidance on safe bathing ranges.
A facility failed to provide trauma-informed care for several residents with PTSD and other behavioral health diagnoses because care plans and trauma screenings did not identify triggers or individualized interventions. Staff interviews showed the Social Worker did not routinely ask about triggers, and multiple residents’ records lacked trigger-specific information even when family or staff later identified possible triggers such as loud noises, waking suddenly, or aggressive males. The facility policy required culturally competent, individualized care that minimizes triggers and re-traumatization.
Medication Error Rate Exceeded Threshold: Surveyors found an 8.82% med error rate based on 3 errors in 34 opportunities. An LVN administered insulin without priming the pen for a resident with DM2, an RN gave Aspirin 81 mg instead of the ordered 325 mg for a resident with heart, kidney, and DM issues, and an RN gave the wrong Cyanocobalamin dose for a resident with vitamin B deficiency and dementia.
Food Not Served at Proper Temperature or Palatability: A resident group reported that food was lousy and cold, and a sampled lunch tray was observed with lukewarm chili bake and carrots, plus brown, soggy, withered salad. An CNA said residents complained the food was not that great, sometimes seasoning or offering an alternative without reporting it, while the ADON, Dietary Manager, and DON acknowledged expectations for food temperature and palatability.
Kitchen Food Safety and Hygiene Deficiencies: Surveyors observed two cans of cut sweet potatoes without dates, a soap dispenser positioned over the clean dish rack, and kitchen staff including the Dietary Manager preparing lunch with hairnets that did not fully cover their heads and loose hair exposed. Staff interviews confirmed that food items should be dated, hair nets should cover the entire head, and the soap dispenser should not be located over clean dishes.
Resident Not Included in Care Plan Conference: A resident with CVA, R-sided weakness, dysphagia, aphasia, and moderate cognitive impairment was not invited to or included in her care plan conference. The record lacked an invitation or attendee signature sheet, and both the resident and family member stated they were not informed of the meeting. The MDS nurse said neither the resident nor family were present, and the SW acknowledged she failed to invite them as required by facility policy.
Failure to issue required Medicare coverage notices for two residents. One resident with intact cognition and a history of TIA was discharged from Part A skilled services before benefits were exhausted, but no NOMNC was completed. Another resident with Alzheimer’s disease and moderately impaired cognition had remaining skilled benefit days when Part A services ended, but no SNF ABN was completed. The MDS Coordinator and DON stated these notices should have been issued when residents continued in the facility after dropping to a non-skilled level of care.
Incomplete Care Plan for Resident Communication Needs: A resident with aphasia, slurred speech, legal blindness, cerebral infarction with R-sided weakness, and HTN had a BIMS score of 9, was bedfast, and was totally dependent for ADLs, yet her care plan did not include a communication focus problem. Staff observed and described her using head nods, facial expressions, and hand gestures to communicate, and the MDS Nurse and DON acknowledged the communication deficit was missed in the care plan.
A resident with Down syndrome, epilepsy, and a cognitive communication deficit did not have the communication board identified in his care plan available in his room. Surveyors observed that he did not respond to questions, and both CNA and LVN staff said they had never seen the board in the room or found it in the bedside storage. The DON stated the board had been ordered and was in the facility before admission, but staff had not notified her that it was missing.
A resident on a mechanical soft diet with nectar-thick liquids was observed without water at the bedside on multiple occasions, and he stated he only received fluids with meals and medications. Staff said thickened fluids were not left in the room and were only brought at set times. In a separate issue, another resident with Alzheimer’s and moderate cognitive impairment did not receive an ordered shake with lunch even though the tray ticket listed it, and staff acknowledged the supplement was missed.
Insulin Pen Not Primed Before Administration: An LVN checked a resident’s blood sugar, prepared NovoLog, and administered the dose without priming the insulin pen first. The resident had DM2 and received scheduled and sliding-scale insulin orders, while the facility skills review and the manufacturer’s insert both required a 2-unit prime before selecting the dose. The LVN said she was unaware priming was required, and the DON said she was also unaware of the need to prime the pen.
Unsecured Medications Found at Bedside: A resident with PTSD, dementia, major depressive disorder, diabetes, and presbyopia had hydrocortisone cream on his bedside table and later on his nightstand, and a tube of Neosporin was also found in his room. The resident said he used the cream for itchy areas on his arm and that a nurse had given it to him. An LVN stated there was no order for bedside meds, and the DON said the resident had been told repeatedly not to keep medications in his room.
A resident with Alzheimer's disease and moderately impaired cognition had a physician order for a cup with lid and straws with every meal, but during observation she did not receive the lid. Staff interviews showed the CNA, dietary aide, Dietary Manager, and DON all recognized the lid was needed and that the order should have been followed, but the tray was still delivered without it.
A Treatment Nurse failed to follow infection control practices during wound care for a resident with a pressure ulcer, diabetes, COPD, obstructive and reflux uropathy, and muscle weakness. The nurse turned off the faucet with her bare hand/wrist after handwashing, including between glove changes, and used the same scissors to remove a soiled dressing and then cut clean dressings without disinfecting them first. The DON stated the expectation was to use a paper towel to turn off the water and clean scissors between dirty and clean surfaces.
A resident with cognitive and physical impairments experienced a violation of dignity and respect when a CNA spoke to her in a rude tone, witnessed by another resident. The incident was reported, and the CNA was terminated due to her negative attitude. The facility's policies emphasize the importance of treating residents with respect, which was not upheld in this case.
A facility failed to accurately complete a PASRR Level I screening for a resident with PTSD and major depressive disorder. The screening incorrectly indicated no mental illness, despite the resident's diagnoses. The social worker was unaware that PTSD could be a PASRR positive diagnosis, and the administrator acknowledged the oversight, which was only corrected after surveyor intervention.
A resident with visual impairment and other medical conditions did not receive a required occupational therapy evaluation for a coffee cup lid, as ordered by a physician. The facility failed to follow the physician's order, leading to a deficiency in care planning. Staff interviews revealed confusion about the order's status, resulting in a lack of action to address the resident's needs.
A resident with heart failure and shortness of breath did not receive proper respiratory care due to a failure to change the filter on their oxygen concentrator. The filter was observed to be dirty on multiple occasions, and staff interviews revealed that the facility's policy of weekly filter cleaning was not followed. This oversight could have put the resident at risk for respiratory complications.
Failure to Maintain Consistently Comfortable Shower Water Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, functional, sanitary, and comfortable environment by not ensuring that water temperatures in two of three communal showers were maintained at a comfortable level for residents. Surveyors reviewed records and interviewed three cognitively intact male residents who used the showers and were generally independent or required limited assistance with bathing. One resident with cerebrovascular disease, diabetes, hypertension, hyperlipidemia, bipolar disorder, anemia, major depressive disorder, and anxiety reported that the shower water was either hot or cold and that the shower "is not worth a crud," although he appeared clean, odor free, and appropriately dressed. Another resident with COPD, hypertension, Parkinson’s disease, peripheral vascular disease, and dementia stated that the water did not stay warm enough for the entire shower, while a third resident with congestive heart failure, atherosclerotic heart disease, hypertension, hyperlipidemia, diabetes, and osteoporosis reported that the water was usually just warm and not as hot as he would like. Observations of the shower rooms on two halls showed that the water temperatures did not reach or maintain a consistently warm range. On the 300 hall, after running the shower for three minutes, the water temperature remained at 85°F; later, after five minutes, it reached 108°F but then dropped back down to 85°F. On the 100 hall, the water temperature reached 103.5°F after three minutes but immediately dropped to 95°F, and a subsequent test showed the water reaching 105°F after three minutes and then dropping below 95°F. Review of facility grievances and resident council minutes for the prior three months did not reveal any documented concerns about shower water temperatures. Staff interviews revealed inconsistent awareness and monitoring of water temperatures. One CNA stated that sometimes water was shut off for repairs with advance notice, that she let the water run to reach a good temperature, and that although some residents wanted hotter water, she believed it was warm enough to complete showers. Another CNA reported no trouble with water temperatures and no resident complaints, stating she adjusted the temperature as needed. An LVN stated that occasionally a resident would say the water was not as hot as they would like, but not that it was cold, and that she would submit a maintenance work order if it occurred consistently. The Maintenance Director acknowledged he was not aware that the 100 and 300 hall showers were not reaching and maintaining a comfortable temperature, did not keep records of shower water temperatures, and had not been routinely taking or documenting them. He described recent water heater replacement issues, noted that the water circulator was out of service, and confirmed that the water temperatures failed to maintain his stated standard of 108°F to 112°F in resident restrooms. The DON stated she did not monitor shower water temperatures and had not received complaints, and the Administrator stated she was not aware that shower water temperatures were not monitored and that she expected weekly monitoring. The facility did not have a policy for shower water temperatures, despite state and federal guidance describing generally accepted safe ranges for bathing water. Title 26 of the Texas Administrative Code cited in the report states that the generally accepted safe range for resident bathing is 100°F to 120°F, with a maximum of 120°F to prevent scalding, and notes that potential for injury can occur below 100°F depending on the individual and exposure time. The State Operations Manual excerpt referenced in the report identifies safe temperature for bathing as 100°F or below, while acknowledging that burns can occur even below 100°F depending on condition and exposure. The facility’s failure to maintain and monitor shower water temperatures within a consistently comfortable range, lack of documentation of temperatures, lack of a specific policy for shower water temperatures, and limited oversight by nursing leadership and administration contributed to the deficiency in providing a safe, functional, sanitary, and comfortable environment for residents using the communal showers.
Trauma-Informed Care Deficiency
Penalty
Summary
The facility failed to ensure that residents with a history of trauma received trauma-informed and culturally competent care that accounted for their experiences and preferences and identified possible triggers to help prevent re-traumatization. The deficiency involved 4 of 5 residents reviewed for trauma-informed care: Resident #2, Resident #7, Resident #8, and Resident #11. The facility’s own policy stated that it would provide care and services using approaches that are culturally competent, account for experience and preferences, minimize triggers and/or re-traumatization, collaborate with residents and others to develop individualized interventions, and identify triggers to be added to the care plan. Resident #2 had diagnoses including PTSD and depression, and his care plan identified a history of trauma but did not address triggers. His trauma screening also did not address triggers. During interview, he stated he had PTSD and said nothing bothered him in the facility, though he reported being spooked when awakened. Resident #7 had diagnoses including PTSD, anxiety, depression, and psychotic disorder with hallucinations. His care plan addressed psychotropic medications and monitoring for side effects, but did not address his trauma history or potential triggers. His trauma screening also did not address triggers. The Social Worker stated she did not ask about triggers when completing the trauma screening and had not been told to ask unless the resident or family volunteered the information. Resident #8 had diagnoses including PTSD, cerebral palsy, schizoaffective disorder, mild intellectual disabilities, and anxiety. Her trauma screening did not identify triggers or describe the PTSD event, and her care plan identified a history of trauma but did not identify the type of trauma or provide interventions. The Social Worker stated the trauma assessment did not ask for triggers and that she did not ask each resident specifically what the triggers were. Resident #8’s family member stated the trauma stemmed from an abusive former marriage and identified a possible trigger as an aggressive male or a male resembling the abusive family member. Resident #11 had diagnoses including PTSD, dementia, major depressive disorder, diabetes mellitus, and presbyopia. His care plan stated staff should assist him in avoiding his triggers, but it did not identify what those triggers were. His trauma screening also did not indicate whether he had triggers. The Social Worker later stated his trigger was loud noises and said she should have alerted him about fire drills and stayed with him for comfort, but the trigger had not been included in the care plan.
Medication Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to ensure it was free from a medication error rate of 5 percent or greater. Surveyors identified 3 medication errors out of 34 opportunities, resulting in an 8.82% error rate, and the errors involved 3 of 5 residents reviewed for medication administration. The deficiencies involved insulin administration for one resident and incorrect doses of Aspirin and Cyanocobalamin for two other residents. For one resident with Type 2 diabetes mellitus, stroke, and high blood pressure, the record showed orders for NovoLog insulin before meals and by sliding scale. During observation, an LVN checked the resident’s blood sugar at 292, prepared the insulin pen, and administered 24 units to the resident’s right arm. The LVN did not prime the insulin pen before giving the dose and stated she was unaware that priming was needed. The LVN acknowledged that priming was important to ensure the resident received the correct dosage. For another resident with heart failure, high blood pressure, kidney failure, and Type 2 diabetes mellitus, the physician ordered Aspirin 325 mg by mouth in the morning for the heart. During observation, an RN checked the MAR and administered Aspirin 81 mg instead. The RN stated she gave the wrong dose because she pulled the wrong bottle. For a third resident with vitamin B deficiency and dementia, the physician ordered Cyanocobalamin 2500 mcg by mouth in the morning. During observation, an RN checked the MAR and administered 2.5 tablets of Cyanocobalamin 500 mcg instead of the ordered 1000 mcg tablets. The RN stated she gave the wrong dose and that the resident did not receive the therapeutic dose needed.
Food Not Served at Proper Temperature or Palatability
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 9 of 9 confidential residents reviewed for food and nutrition services. During a confidential resident group meeting, 9 residents stated the food was lousy and cold. During an observation on 12/09/25 at 12:16 p.m., a lunch tray sampled by the Dietary Manager and six surveyors included chili bake that was lukewarm, carrots that were lukewarm, and salad that was brown, soggy, and withered. During interviews, CNA L stated residents had complained that the food was not that great and that she would sometimes try to season it with salt and pepper or offer an alternative, but she did not report the complaints to anyone. The ADON stated that if residents complained about cold or bland food, an alternative would be offered and that all food complaints should be reported to the DON and Dietary Manager. The Dietary Manager stated she had not received complaints in the last several months, that she monitored meal service daily including random tray sampling, and that food complaints were usually handled verbally with an alternative offered. The DON stated she expected food to be the appropriate temperature and seasoned for palatability. The facility policy stated the Dietary Service Manager or designee is responsible for ensuring proper preparation of food that conserves nutritive value, flavor, and appearance, tasting all foods prior to serving, and presenting meals in a manner that enhances plate appearance.
Kitchen Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety for 1 of 1 kitchen reviewed. During the initial tour observation on 12/08/25, two cans of cut sweet potatoes were observed undated. The Dietary Manager was also observed with a soap dispenser located over the clean dish rack next to the three-compartment sink, creating a condition where staff could contaminate the clean dish rack while using the soap dispenser. During the same observation, [NAME] O, [NAME] P, and the Dietary Manager were preparing the lunch meal with hairnets that did not cover the entire head, and loose hair was sticking out. Interviews with Dietary Aide F, [NAME] Q, the Dietary Manager, and the DON confirmed that food items should be dated, hair nets should cover the entire head without loose hair sticking out, and the soap dispenser should not be over the clean dish rack. The Dietary Manager stated she was responsible for monitoring daily walk-throughs and that these failures could potentially put residents at risk for cross contamination and foodborne illness.
Resident Not Included in Care Plan Conference
Penalty
Summary
The facility failed to ensure Resident #47 was invited to and included in the development and implementation of her person-centered plan of care. Resident #47 was a [AGE]-year-old female admitted with diagnoses including cerebral infarction with right-sided weakness, hypertension, dysphagia, aphasia, and visuospatial deficits. Her comprehensive MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and documented that she had upper and lower extremity range of motion impairment, used a wheelchair for mobility, required set-up assistance with self-feeding, was dependent for toilet hygiene, bathing, and transfers, and needed moderate assistance with upper body dressing and maximum assistance with lower body dressing and bed mobility. Record review showed her care plan was initiated and completed, but the record did not include an invitation for Resident #47 and/or her responsible party to the care plan meeting or a signature sheet of attendees. During interviews, Resident #47 stated she had not attended or been informed of a care plan conference meeting, and her family member stated she had not been invited or informed of a care plan meeting since admission. The MDS Nurse stated neither the resident nor family members were present at the care plan review and believed the Social Worker was responsible for inviting them. The Social Worker stated she was responsible for informing and inviting residents and/or responsible parties to the care plan conference meeting, acknowledged that the review had already been completed without inviting Resident #47 or her responsible party, and stated she failed to do so. The DON stated the resident and/or responsible party should participate in the care plan conference meeting either in person or by phone, and the facility policy required the Social Worker to send invitation letters to the resident, family member, or responsible party.
Failure to Issue Required Medicare Coverage Notices
Penalty
Summary
The facility failed to ensure that residents were informed before or at admission, and periodically during their stay, about services available in the facility and charges for those services, including charges for services not covered under Medicare/Medicaid or by the facility’s per diem rate. For Resident #15, a male admitted with a diagnosis including transient cerebral ischemic attack, the quarterly MDS reflected that he made himself understood and understood others, and his BIMS score was 15, indicating intact cognition. His SNF Beneficiary Notification Review showed he received Medicare Part A skilled services starting 07/20/25, with the last covered day on 08/15/25, and that the facility/provider initiated discharge from Part A services before benefits were exhausted; a NOMNC was not completed. For Resident #19, a female admitted with a diagnosis including Alzheimer’s disease, the quarterly MDS reflected that she usually made herself understood and usually understood others, and her BIMS score was 8, indicating moderately impaired cognition. Her SNF Beneficiary Protection Notification Review showed she was receiving Medicare Part A services starting 10/07/25, with the last covered day on 10/13/25, and that a SNF ABN was not completed even though she had remaining skilled benefit days. During interview, the MDS Coordinator stated she was responsible for ensuring Resident #19 was issued a SNF ABN and that the previous MDS Coordinator would have been responsible for Resident #15’s NOMNC; she also stated the forms should have been issued when residents had skilled benefit days remaining and were discharged from Part A services but continued in the facility. The DON stated she expected the SNF ABN and NOMNC to be given under those circumstances, and the facility policy stated the notices were intended to be delivered in a timely manner when a beneficiary dropped to a non-skilled level of care and benefits had not exhausted.
Incomplete Care Plan for Resident Communication Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one resident that included measurable objectives and time frames to meet identified mental, nursing, and psychosocial needs. Resident #1 was a female with diagnoses including aphasia, slurred speech, legal blindness, cerebral infarction with right-sided weakness, and hypertension. Her comprehensive MDS showed a BIMS score of 9, unclear speech, that she was sometimes understood and understood others, as well as upper and lower extremity range of motion impairment, bedfast status, and total dependence in all activities of daily living including eating, dressing, toileting, bathing, transfers, and mobility. Record review showed the resident’s comprehensive care plan with a target completion date of 11/07/2025 did not include a care plan addressing her communication deficit. During observation, the resident responded to surveyor questions with head nods and facial expressions only, with no attempt at verbal communication. CNA A stated the resident does not speak and uses head nods to communicate needs. The Social Worker stated the resident has a communication problem and uses head nods, hand gestures, and facial expressions, and the MDS Nurse stated the interdisciplinary team did not catch that communication was not identified in the plan of care during the last care plan review. The DON stated the care plan should have included a communication focus problem with appropriate interventions specific to the resident.
Missing Communication Board for Resident with Communication Deficit
Penalty
Summary
The facility failed to provide the necessary care and services to ensure that Resident #48’s abilities in activities of daily living did not diminish based on his comprehensive assessment and needs. Resident #48 was a male admitted with diagnoses including Down syndrome, epilepsy, and cognitive communication deficit. His admission MDS indicated he usually understood others and could usually make himself understood, but also showed a BIMS score of 99 because he was unable to complete the assessment and that he had moderately impaired cognition. The care plan identified a communication deficit related to severe intellectual disabilities and included an intervention to ensure availability and functioning of adaptive communication equipment, specifically a communication/message board. Record review and observations showed the communication board was not present in the resident’s room. During observations, the resident did not respond to questions, and surveyors could not get him to nod yes or no. The roommate was unaware of any communication tools being used. CNA N stated the resident was more hands-on than verbal, had never seen a communication board, and found none in the bedside drawers or nightstand. LVN D also stated she had never seen a communication board in the room and noted the care plan indicated the resident should have had one. The DON stated the facility had ordered a communication board and it was in the facility prior to admission, but no one had notified her that it was missing. A family member also said she had never seen a communication board in the room and wished the resident had one.
Failure to Provide Ordered Fluids and Supplement
Penalty
Summary
The facility failed to ensure Resident #13 had sufficient access to thickened fluids to maintain hydration. Resident #13 was admitted with diagnoses including diabetes mellitus, COPD, obstructive and reflux uropathy, and muscle weakness. His admission MDS showed moderate cognitive impairment, dependence for toileting and bathing, moderate assistance with bed mobility, and set-up assistance with eating. His care plan and physician orders indicated a mechanical soft diet with mildly thickened nectar liquids, and the care plan identified a goal to maintain adequate hydration with interventions to provide nectar thickened liquids as ordered. During observations on 12/08/25, 12/09/25, and 12/10/25, Resident #13 was seen without water at his bedside or in his room. On 12/08/25, he told the surveyor the facility made thickened liquids but did not leave any in the room for him to drink, and he said he never had water except on his food trays. He also stated he was worried because he had a urinary tract infection while in the hospital and said he was not offered fluids at other times. Staff interviews reflected that fluids were sent with meals and medications, that thickened fluids were not left in the room, and that residents would need to ask staff for drinks between those times. The DON stated the CNAs were supposed to bring water for residents daily at 10:00 AM, 2:00 PM, and 8:00 PM, and also stated the facility did not leave thickened water at the bedside because it could change consistency. The facility also failed to ensure Resident #19 received a prescribed supplement with meals. Resident #19 had Alzheimer’s disease, a BIMS score of 8 indicating moderate cognitive impairment, and was independent with eating. Her order summary included ensure twice a day, and her care plan identified risk for nutritional and hydration issues related to Alzheimer’s, dementia, BIMS score, and recent acute illness, with interventions to provide ensure as ordered. During observation and record review, Resident #19 did not receive a shake with her lunch meal even though the meal ticket reflected a 4 oz nutritious shake. The resident stated she was supposed to get a milk shake with her meals. Staff interviews showed the CNA, dietary aide, dietary manager, and DON each identified that the shake should have been provided and that it was not received because of a mistake or failure to verify the tray before delivery.
Insulin Pen Not Primed Before Administration
Penalty
Summary
The facility failed to ensure that Resident #15 was free from a significant medication error during insulin administration. Resident #15 was a male with diagnoses including type 2 diabetes mellitus, stroke, and high blood pressure. His quarterly MDS indicated he could make himself understood and understood others, with a BIMS score of 15, and his care plan directed staff to check blood sugars, give diabetes medication as ordered, and observe for adverse side effects and complications such as hypoglycemia. Physician orders included NovoLog FlexPen 20 units subcutaneously before meals and an additional sliding-scale NovoLog dose before meals and at bedtime based on blood sugar results. During an observation and interview, the LVN checked Resident #15’s blood sugar and obtained a reading of 292, then prepared the NovoLog pen and administered 24 units to the resident’s right arm. The LVN did not prime the insulin pen before selecting and giving the dose, and stated she was unaware that priming was required before administration. The DON later stated she expected the nurse to check the blood sugar and give the ordered insulin dose, but she was unaware the insulin pen needed to be primed before use. The facility’s Licensed Nurse Skills Review required a 2-unit prime every time before selecting the dosage, and the manufacturer’s insert for NovoLog stated the pen must be primed before administration.
Unsecured Medications Found at Bedside
Penalty
Summary
The facility failed to ensure all drugs were stored in a locked compartment and labeled and dated correctly for one resident observed for medication storage. Resident #11, a male with diagnoses including PTSD, dementia, major depressive disorder, diabetes mellitus, and presbyopia, had hydrocortisone 1% cream on his bedside table during an observation on 12/09/2025, and the resident stated he used it for areas on his arm when he scratched and that a nurse had given it to him. During another observation on 12/10/2025, the hydrocortisone cream was again found in his room on his nightstand while he was out of the room. The resident’s order summary listed hydrocortisone external cream 1% to be applied topically every 12 hours as needed for itching, but it did not include an order for Neosporin. During interview, an LVN stated the facility did not have an order for anyone to keep medications at bedside and that Resident #11 should not have the hydrocortisone in his room. Later, the DON stated she found hydrocortisone 1% cream and a tube of Neosporin in the resident’s room when she cleaned it out, and said the resident had been told repeatedly that he could not have medications in his room. The facility policy stated all drugs and biologicals were to be stored in locked compartments.
Failure to Provide Ordered Cup Lid With Meals
Penalty
Summary
The facility failed to provide special eating equipment and utensils for a resident who had a physician's order for a cup with lid and straws with every meal. Resident #19 was an elderly female admitted with a diagnosis of Alzheimer's disease, and her quarterly MDS reflected a BIMS score of 8, indicating moderately impaired cognition. Her order summary listed regular texture, thin consistency, fortified foods, and a cup with lid and straws with every meal, with a start date of 10/07/25. Her care plan identified her as at risk for nutritional and hydration issues related to Alzheimer's, dementia, BIMS score, and recent acute illness. During an observation and interview, Resident #19 did not receive a lid with her cup, and she stated she did not know if she needed one. A CNA stated the nurse must check trays before passing them out and that the lid was important to prevent spillage. A dietary aide stated she was responsible for ensuring the lid was on the cup before delivering the tray and said it was a mistake that it was not provided. The Dietary Manager and DON both stated the resident should have received the lid, and the DON stated she expected the physician diet order to be followed. The facility policy stated menus would be followed and served as written.
Infection Control Failures During Wound Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program for Resident #13 during wound care to the right heel. Resident #13 was an [AGE]-year-old male admitted with diagnoses including diabetes mellitus, chronic obstructive pulmonary disease, obstructive and reflux uropathy, and muscle weakness. His admission MDS indicated he understood others, could make himself understood, had a BIMS score of 11, and required staff assistance with toileting, bathing, bed mobility, and eating. His care plan identified a pressure ulcer and risk for infection, pain, and decline in functional abilities, with interventions for wound care per physician order and keeping the dressing clean, dry, and intact. During observation of wound care, the Treatment Nurse performed hand hygiene at the sink in the resident’s bathroom but turned off the faucet with her bare hand/wrist after washing, including between glove changes and again at the completion of care. The nurse also cleaned her scissors before starting the procedure, used the scissors to remove the soiled dressing from the right heel, placed the dirty scissors back on a clean surface, and did not clean or disinfect them before using the same scissors to cut clean dressings for application to the open wound. In interview, the Treatment Nurse stated she should have used a paper towel to turn off the water and should have cleaned the scissors after cutting the dirty dressing. The DON stated the expectation was for the treatment nurse to use a paper towel to turn off the water and clean scissors between clean and dirty surfaces.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. The resident, who had a history of slurred speech, anxiety disorder, muscle weakness, and hemiplegia following a stroke, required maximal assistance for activities of daily living. During an interaction, the CNA spoke to the resident in a rude tone, which was witnessed by another resident. The CNA reportedly told the resident, "Oh no ma'am, we are not fixing to do this because I am not going to be the one," which was perceived as disrespectful and hurtful by the resident. The incident was reported by the witnessing resident to the facility's administration and Director of Nursing (DON), who assured the resident that such behavior would not be tolerated. The CNA involved in the incident acknowledged the event, explaining that the resident had become upset when the metal part of a gait belt accidentally hit her. The CNA claimed to have apologized and reported the incident to her charge nurse. However, the CNA was subsequently terminated from her position at the facility. Interviews with other staff members and residents revealed mixed perceptions of the CNA's behavior, with some describing her as a good worker, while others noted her loud demeanor and occasional rudeness. The DON and Administrator confirmed that the CNA was let go due to her negative attitude, which was not conducive to the facility's environment. The facility's policies on resident rights and dignity emphasize the importance of treating residents with respect, which was not upheld in this incident.
Inaccurate PASRR Level I Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASRR) Level I assessment for a resident, which did not reflect the resident's mental health status. The resident, who was readmitted to the facility, had a diagnosis of post-traumatic stress disorder (PTSD) and later received a diagnosis of major depressive disorder. Despite these diagnoses, the PASRR Level I screening incorrectly indicated that the resident did not have a mental illness. This oversight was identified during a survey, and it was noted that the facility had not updated the PASRR Level I screening to reflect the new diagnosis until prompted by the surveyor. The facility's policy required that if a resident had a qualifying mental illness diagnosis, the PASRR Level I should be marked accordingly, and any changes should be communicated to the local health authority using a 1012 form. However, the social worker was unaware that PTSD could be a PASRR positive diagnosis, leading to the failure to update the screening. The administrator acknowledged that the screening should have been marked to indicate the presence of a mental illness, which would have allowed for an evaluation by the local health authority and potentially provided PASRR services to the resident.
Failure to Implement Physician Order for Occupational Therapy Evaluation
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as Resident #28, who had multiple medical conditions including exudative age-related macular degeneration, muscle weakness, unsteadiness on feet, lack of coordination, and a cognitive communication deficit. The resident had a history of spilling coffee, which resulted in a minor burn, and was supposed to be evaluated by occupational therapy for a coffee cup lid as per a physician's order dated 03/31/2024. However, this evaluation was not conducted, and the order was not followed, leading to a deficiency in care planning. The report details that the resident was independent in some activities of daily living but required assistance with others due to her visual impairment and other conditions. Despite a physician's order for an occupational therapy evaluation to address the coffee spill incident, the facility did not implement this order. Interviews with staff revealed confusion about whether the order was a true physician's order or merely an intervention, leading to a lack of follow-through on the necessary evaluation. The facility's policies on comprehensive care plans and following physician orders were not adhered to, as evidenced by the failure to conduct the occupational therapy evaluation. Staff interviews indicated a lack of communication and understanding regarding the implementation of physician orders, contributing to the deficiency. The Director of Nursing and other staff acknowledged the expectation to follow physician orders, yet the order for the coffee cup lid evaluation was not executed, highlighting a gap in the facility's care planning process.
Failure to Maintain Oxygen Concentrator Filter
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically by not changing the filter on an oxygen concentrator machine used by a resident. The resident, a male with heart failure and shortness of breath, was observed on multiple occasions with a dirty oxygen concentrator filter that had a thick layer of white/gray material. Despite being admitted recently, the filter was not checked or changed, which was against the facility's policy of weekly cleaning. Interviews with staff revealed that the nurses were supposed to check the concentrator filters weekly, but this was not done for the resident in question. The LVN and Hall Manager admitted to not checking the filter, and the ADON and DON acknowledged the oversight. The facility's policy required weekly cleaning of the filter, but this was not adhered to, potentially putting the resident at risk for respiratory complications.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 18 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Clarksville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Focused Care At Clarksville | 2 mi | ★★★★★ | 8 | 0 |
| Hill Nursing Home, Inc. | 23.9 mi | ★★★★★ | 0 | 0 |
| Memorial Heights Nursing Center | 24.2 mi | ★★★★★ | 10 | 0 |
| Heritage House At Paris Rehab & Nursing | 26.5 mi | ★★★★★ | 13 | 0 |
| Greenhill Villas | 28.7 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.