Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Focused Care At Clarksville during CMS and state inspections, most recent first.
Inaccurate MDS Assessments for PASRR Status and Tobacco Use: The facility failed to code a resident’s PASRR positive status, another resident’s tobacco use, and another resident’s PASRR positive status on MDS assessments. Records, care plans, PASRR documents, and direct observations showed one resident was PASRR positive for mental illness, one resident smoked daily with staff supervision, and another resident met criteria for mental illness and special services, yet the MDSs did not reflect those findings.
Failure to Count Controlled Substances and Remove Expired Medications: Staff did not count narcotics when a medication cart changed hands after an MA left unexpectedly, and expired meds were found on a medication cart and in the med room. The expired items included meds labeled for residents with HTN, HF, COPD, smoking history, and depression. Staff, the DON, the Administrator, and the Pharmacy Consultant all stated the expired meds should have been removed and that the narcotics should have been counted during the transfer.
Infection control failures were observed during incontinent care, a Hoyer lift transfer, and wound care for two residents. CNAs and an LVN kept gloves in pockets, used gloves from pockets, changed gloves without hand hygiene, touched clean items without hand hygiene, and left a resident room without washing hands. One resident was dependent for toileting and another had paraplegia, an indwelling catheter, bowel incontinence, and an unhealed stage 4 pressure ulcer on EBP.
A resident with schizophrenia, schizoaffective disorder, psychotic disorder with hallucinations, and bipolar disorder did not have a care plan addressing his PASRR positive status. Records showed he met criteria for mental illness and qualified for special services, but the revised care plan did not include this need. The DON and MDS Nurse both stated the care plan should have addressed the resident’s PASRR positive status.
Two residents had antibiotic orders without stop dates or documented justification for extended use. One resident with prostate cancer and paraplegia received Methenamine Hippurate for urinary antiseptics, and another resident with kidney failure received Bactrim DS for chronic UTIs. The IP noted no physician documentation for the orders, and the DON stated extended antibiotic use should be supported by documentation and follow-up. The facility’s ASP policy required indication, dosage, duration, and clinical justification for use beyond the initial duration ordered.
Kitchen Gas Stove Not Maintained in Safe Operating Condition: A gas stove in the kitchen was observed with two right burners that would not ignite when turned on, and the pilot lights were not lit. The DM said the burners had to be lit with a long lighter and that the stove should light without using a lighter. The Administrator stated kitchen equipment was expected to work correctly and acknowledged the gas stove could cause a fire and possible injuries.
Staff failed to protect residents from misappropriation of property and medications, including a medication aide removing prescription drugs from medication carts for personal use and a housekeeper accepting cash from a resident without providing the requested items. Residents affected had significant cognitive and medical needs, and staff interviews revealed inconsistent practices for securing and disposing of medications.
The facility failed to properly date and dispose of expired food items, and residents were observed self-serving ice, posing risks of foodborne illness and cross-contamination. The Dietary Manager and staff were aware of some issues but did not fully adhere to food safety and infection control policies.
A resident with a history of hemiplegia and other health conditions was found smoking alone in the designated area, contrary to the facility's policy requiring supervision and secure storage of smoking materials. The resident accessed cigarettes unsupervised, and staff failed to ensure compliance with the smoking policy, placing the resident at risk of safety hazards.
A resident had several medications, including Vagisil cream and fluticasone nasal spray, stored in her room and bathroom, accessible to unauthorized individuals. The facility failed to secure these medications as required, and the resident's electronic medical record did not indicate a self-administration assessment. The DON and Administrator acknowledged the oversight, emphasizing that all staff were responsible for ensuring medications were not left in residents' rooms.
Two CNAs failed to use enhanced barrier precautions during foley care for a resident with an indwelling catheter, leading to a deficiency in the facility's infection prevention and control program. The CNAs did not wear gowns and failed to change gloves after the procedure, touching clean surfaces and the resident with the same gloves. The resident, who had multiple health conditions, required enhanced precautions to prevent infections. Despite being aware of the protocol, the CNAs did not adhere to it due to nervousness and oversight.
A resident's bathroom toilet was not functioning properly, with issues of running and leaking water persisting despite being reported to staff. The Maintenance Director was aware of the problem but did not document it, believing it was fixed. The ongoing issue placed the resident at risk for falls, contrary to the facility's policy of providing a safe and homelike environment.
A resident's controlled medications, including Hydrocodone-Acetaminophen and Lorazepam, were misappropriated after their death in an LTC facility. An RN was alleged to have stolen the narcotics, with initial drug tests showing positive for opiates. The facility's procedures for handling narcotics were scrutinized, revealing discrepancies in medication counts and highlighting the risk to residents' quality of life and dignity.
A facility failed to protect a resident from abuse when a female resident with severe cognitive impairment was found in a compromising situation with a male resident with moderate cognitive impairment. The incident involved inappropriate sexual touching, and both residents later showed no recollection of the event. The facility's policy on abuse was not effectively implemented, contributing to the occurrence of the event.
Inaccurate MDS Assessments for PASRR Status and Tobacco Use
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected resident status for 3 of 15 residents reviewed. Resident #7’s significant change MDS, dated 10/14/2025, did not indicate current PASRR positive status even though the care plan identified the resident as PASRR positive for mental illness related to anxiety and depression and noted a recent psychiatric inpatient stay. The facility’s undated PASRR positive resident list also identified Resident #7 as PASRR positive and refusing services. The resident’s record showed diagnoses of anxiety and major depressive disorder, and the MDS recorded a BIMS score of 15. Resident #8’s annual MDS, dated 04/29/2025, did not mark current tobacco use during the assessment period. The resident’s record showed a diagnosis of COPD, and the care plan identified the resident as a smoker with interventions for staff to keep all lighters and provide supervised smoking breaks. A Safe Smoking Assessment dated 04/28/2025 stated the resident required direct supervision while smoking and that all smoking materials were to be kept at the nurse’s station. During observation and interview, Resident #8 stated she smoked daily and that staff kept her smoking supplies and monitored her during smoking times; staff were observed lighting her cigarette and supervising the smoking episode. LVN A also stated the resident smoked daily and that staff kept her smoking supplies, lit her cigarettes, and monitored her during smoking episodes. Resident #36’s annual MDS did not mark A1500 as yes for current PASRR serious mental illness status. The record included a PASRR Level 1 Screening dated 08/19/25 showing the resident was discharged from a psychiatric hospital and marked yes for mental illness, and an LMHA letter dated 08/20/25 stating the resident met criteria for mental illness and qualified for special services. During interview, the DON stated she was not familiar with PASRR or MDS requirements and said she thought the MDS should reflect PASRR positive status even if the resident refused services. The MDS Nurse stated Resident #8’s smoking status should have been coded and Resident #7’s PASRR status should have been coded positive, and the DON and Administrator stated they expected all MDSs to be correct and accurate.
Failure to Count Controlled Substances and Remove Expired Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet resident needs by not ensuring controlled substances were counted when medication cart keys changed hands and by not removing expired medications from medication carts and the medication storage room. During an observation on 02/23/2026, MA B handed her medication cart keys to LVN A and left the facility because of a family emergency. LVN A stated the narcotics on the cart were not counted before MA B left, and both staff acknowledged they knew the narcotics should have been counted during the transfer of responsibility. The report also identified expired medications on a medication cart used for residents including one labeled for a resident with HTN and HF and another labeled for a resident with HTN. On the cart, surveyors found diltiazem HCL 180 mg with a use-by date of 12/24/2025 and amlodipine 5 mg with a use-by date of 05/02/2025. LVN C stated staff who gave medications from the cart were responsible for removing expired medications and placing them in the destruction bin, and said the expired medications had been overlooked. In the medication storage room, surveyors found additional expired items, including Guardian brand fiber powder with an expiration date of January 2026, nicotine transdermal patches labeled for a resident with COPD and smoking history with an expiration date of April 2025, a bottle of one-a-day vitamin with minerals with an expiration date of 11/2025, and venlafaxine HCL ER labeled for a resident with depression with an expiration date of 9/2025. LVN D, the DON, the Administrator, and the Pharmacy Consultant each stated staff were responsible for removing expired medications from the carts and medication room, and that the expired medications found had been overlooked.
Infection Control Lapses During Incontinent Care, Transfer, and Wound Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program during observed incontinent care and transfer care for a cognitively intact resident who was dependent on assistance with toileting. During care, two CNAs had gloves in their pockets, changed gloves without hand hygiene between glove changes, touched clean items without hand hygiene, and one CNA left the room without washing her hands after providing incontinent care and a Hoyer lift transfer. When interviewed, one CNA stated they should have changed gloves with hand hygiene between and that staff should always wash their hands when entering and exiting a resident room. The facility also failed during observed incontinent care and wound care for a resident with malignant neoplasm of the prostate, paraplegia, an indwelling urinary catheter, frequent bowel incontinence, and an unhealed stage 4 pressure ulcer who was on Enhanced Barrier Precautions for catheter and wound care. A CNA pulled gloves from her pocket during incontinent care, and an LVN used gloves given from the CNA’s pocket during wound care after running out of gloves. The LVN did not perform hand hygiene between glove changes while cleaning the sacral wound. The DON stated staff should place gloves in a plastic bag, wash hands after cleaning a resident with a bowel movement and when entering or exiting a resident room, and always perform hand hygiene between glove changes. The Administrator stated staff should follow the policies on hand hygiene and glove use.
Care Plan Missing PASRR Positive Status
Penalty
Summary
Resident #36 did not have a comprehensive person-centered care plan that addressed his PASRR positive status. Record review showed he was admitted with diagnoses including schizophrenia, schizoaffective disorder, psychotic disorder with hallucinations, and bipolar disorder. A PASRR Level 1 Screening dated 08/19/25 indicated he was discharged from a psychiatric hospital, marked no for dementia as a primary diagnosis and yes for mental illness, and a LMHA letter dated 08/20/25 stated he met criteria for mental illness and qualified for special services. The care plan revised 01/09/26 had no care plan addressing his PASRR positive status. During observation on 02/23/26, he was in bed watching TV and stated he had a headache since he bruised his brain in 1976 and that medications did not really help, but he said he had no issues with his care. The DON stated he should have a care plan indicating he was PASRR positive even though he refused services, and the MDS Nurse said the care plan should have addressed his PASRR positive status. The facility policy stated every resident will have an individualized interdisciplinary plan of care, with a baseline plan developed within 48 hours of admission and the plan revised as needed.
Unnecessary Antibiotic Orders Without Stop Dates or Documentation
Penalty
Summary
The facility failed to ensure that two residents’ drug regimens were free from unnecessary medications because antibiotic orders did not have stop dates and there was no documented justification for the extended duration of use. Resident #5, a readmitted male with diagnoses including malignant neoplasm of the prostate and paraplegia, had an order for Methenamine Hippurate 1 GM by mouth twice a day for urinary antiseptics, dated 12/26/25, with no stop date. A physician progress note dated 01/29/26 did not document a reason for the lack of a stop date on the order. Resident #32, a readmitted female with kidney failure, had an order dated 01/28/2026 for Bactrim DS 800-160 mg by mouth one time a day for chronic UTIs, also without a stop date. A physician progress note dated 01/29/26 did not document a reason for the lack of a stop date on the order. During interviews, the IP stated she believed the antibiotic was ordered prophylactically for UTI and did not see physician notes about it, the DON stated there should be documentation to support extended antibiotic use and resident follow-up, and the Administrator stated staff and physicians were expected to follow protocols regarding antibiotic orders. The facility’s Antibiotic Stewardship Program policy required prescription documentation to include indication for use, dosage, duration, and clinical justification for antibiotic use beyond the initial duration ordered.
Kitchen Gas Stove Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to maintain the kitchen gas stove in safe operating condition for 1 of 1 stove reviewed as essential equipment. During an observation and interview, the two right burners would not ignite when the knobs were turned on, and the pilot lights to those burners were not lit. The DM stated the burners had to be lit with a long lighter and said the stove should light without using a lighter. Observation also indicated there was no hissing sound of gas and no foul smell of gas coming from the burners. During a later interview, the DM said the MD had looked at the stove after the surveyor observed the problem and it still had a problem, although there was no gas coming out unless the knobs were turned on. The Administrator stated she expected kitchen equipment to be working correctly and acknowledged that because the stove was gas it could cause a fire and possible injuries. Record review showed the facility had a policy for monthly inspections of kitchen equipment and the FDA Food Code requirement that equipment be maintained in a state of repair and proper adjustment.
Failure to Prevent Misappropriation of Resident Property and Medications
Penalty
Summary
The facility failed to protect residents from the misappropriation of their property and funds, resulting in multiple incidents involving both medication and money. A medication aide (CMA) removed various prescription medications, including Megace, Zofran, Pantoprazole, and others, from the medication carts without authorization and for personal gain. These medications were prescribed to residents with significant cognitive impairments and complex medical conditions, such as Alzheimer's disease, dementia, diabetes, and hypertension. The medications were later found at the CMA's home during a police investigation, and the CMA admitted to taking non-narcotic medications that were left on the countertop instead of being secured in the locked cabinet as required by facility policy. Additionally, a housekeeper accepted cash from a resident with moderate cognitive impairment, who had given the money in hopes of receiving personal items. The housekeeper did not return the money or provide the items, and subsequently left employment at the facility. The resident was unable to recall the exact amount given, but it was reported to be $60. The incident was reported to the police, and the housekeeper later admitted to taking the money and claimed to have purchased some items, though this was not verified by the resident or facility records. Interviews with staff revealed inconsistent understanding and implementation of the facility's procedures for medication disposal and handling of resident property. Several staff members described varying practices for securing and disposing of medications, with some indicating that non-narcotic medications were sometimes left on countertops rather than being immediately secured. The facility's failure to ensure consistent adherence to policies and procedures for safeguarding resident property and medications directly led to the misappropriation incidents.
Deficiencies in Food Safety and Infection Control
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen and dietary services. During inspections, it was noted that food items were not properly dated, and expired food was not disposed of. Specifically, an unopened gallon of milk was found expired, and a serving of hot sauce was past its prep date. Additionally, several containers of cereal and spices were either missing use-by dates or were past their expiration dates. The Dietary Manager acknowledged these issues, stating that all food items should be labeled with receive, open, and expiration dates, and admitted to being aware of some of the labeling deficiencies. Furthermore, the facility did not maintain proper infection control measures, as residents were observed self-serving ice from an ice chest cooler. This practice was noted on multiple occasions, and staff interviews revealed a lack of awareness regarding the potential for cross-contamination. RN C and the ADON both acknowledged the infection control risks associated with residents self-serving ice, yet were unaware of the practice until it was pointed out by surveyors. The DON and Administrator also confirmed that residents should not be self-serving ice due to the risk of cross-contamination. The facility's policies on food safety and infection control were not being followed, as evidenced by the observations and staff interviews. The Food Safety policy required all food to be labeled and dated, while the Infection Control policy emphasized preventing the transmission of disease. Despite these policies, the facility's practices fell short, leading to potential risks for foodborne illness and infection among residents.
Failure to Supervise Resident Smoking
Penalty
Summary
The facility failed to ensure a safe environment for a resident who was reviewed for accident hazards. The resident, who had a history of hemiplegia following a cerebral infarction, diabetes mellitus, depression, high blood pressure, and lack of coordination, was found smoking alone in the designated smoking area. Despite the facility's policy requiring supervision during smoking and secure storage of smoking materials, the resident was able to access and use cigarettes unsupervised. The resident's care plan specified supervised smoking privileges, and the facility policy mandated that all smoking materials be kept in a locked box at the nurse's station. During an observation, the resident was found smoking alone, and she did not disclose who provided her with the cigarette or who lit it. The Director of Nursing (DON) confirmed that the resident had cigarettes in her pocket and refused to reveal their source. The Administrator acknowledged that the resident could obtain cigarettes while out on pass with friends and family, but expected all smoking items to be secured upon return. The facility's failure to adhere to its smoking policy placed the resident at risk of burns, safety hazards, or respiratory issues.
Unauthorized Access to Medications in Resident's Room
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and allowed unauthorized access to medication for one resident. Specifically, Resident #14 had several medications, including Vagisil cream, Preparation H ointment, Aspercreme lidocaine roll-on, fluticasone nasal spray, and Systane eye drops, stored in her room and bathroom, accessible to unauthorized staff, residents, or visitors. These medications were not locked away as required by facility policy. Resident #14, a cognitively intact female with a BIMS score of 14, was admitted to the facility with diagnoses including high blood pressure, arthritis, and seasonal allergies. Her care plan indicated a need for assistance with ADLs and medication administration, and she was at risk for a decrease in ADLs and injuries. Despite this, her electronic medical record did not indicate a self-administration assessment, and she had medications in her possession that were not ordered by the facility. Observations revealed that Resident #14 had medications in her room and bathroom, which were not secured. A CNA confirmed that these medications should not have been in the resident's room and removed them. The DON and Administrator acknowledged the failure to secure medications and stated that all staff were responsible for ensuring medications were not left in residents' rooms. The facility's policy required medications to be stored safely and securely, accessible only to authorized personnel.
Infection Control Deficiency in Foley Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during foley care for a resident. The CNAs did not adhere to enhanced barrier precautions, which required donning a gown, while performing foley care on a resident with an indwelling catheter. This oversight was observed during a survey, where the CNAs only wore gloves and failed to change them after completing the foley care, subsequently touching clean surfaces and the resident with the same gloves. The resident involved was an elderly male with multiple diagnoses, including Parkinson's disease, type 2 diabetes, hyperlipidemia, and obstructive and reflux uropathy. He was dependent on staff for toilet hygiene and transfers and had a foley catheter, which necessitated enhanced barrier precautions to prevent infections. Despite the presence of signs in the resident's room indicating the need for such precautions, the CNAs did not follow the required protocol. Interviews with the CNAs revealed that they were aware of the need for enhanced barrier precautions but failed to implement them due to nervousness and oversight. The ADON, who was responsible for training and evaluating staff on infection control practices, had not yet completed skills evaluations for the staff, including the CNAs involved. The DON and Administrator both emphasized the importance of following infection control procedures to prevent cross-contamination and infection, highlighting the deficiency in the facility's infection prevention and control program.
Failure to Maintain Functional and Safe Bathroom Facilities
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for a resident, specifically regarding the functionality of the bathroom toilet. The resident, who was cognitively intact and able to communicate, reported that her toilet had been running and leaking since her admission. Despite informing the staff, the issue persisted, and the maintenance request was not documented in the maintenance book. The Maintenance Director was aware of the problem three weeks prior but did not document it, believing he had fixed the issue by replacing the toilet flapper. However, the problem continued, as observed by surveyors, with water leaking onto the floor. The Director of Nursing (DON) and the Administrator both acknowledged the expectation for the toilets to be functional and not leaking, with the Maintenance Director responsible for ensuring this. The failure to maintain the toilet placed the resident at risk for falls, as confirmed by the Maintenance Director and the DON. The facility's policy on providing a safe and homelike environment was not adhered to, as evidenced by the ongoing issue with the resident's toilet.
Misappropriation of Resident's Medications After Death
Penalty
Summary
The facility failed to protect a resident's property from misappropriation, specifically involving the diversion of controlled medications after the resident's death. The medications in question included Hydrocodone-Acetaminophen and Lorazepam, which were not found after the resident expired. The incident involved a registered nurse (RN A) who was alleged to have stolen narcotics from the facility. Despite the nurse's denial, a drug test initially showed positive results for opiates, although the final results were negative. The investigation revealed that RN A had access to the medication carts containing the resident's medications. Interviews with various staff members, including licensed vocational nurses (LVNs) and medication aides (MAs), indicated that routine procedures involved leaving discontinued medications on the cart and counting them against the Controlled Drug Administration Record when the Director of Nursing (DON) was not present. However, discrepancies were noted when the DON reconciled the pharmacy manifest with the Controlled Drug Administration Record, highlighting the missing medications. The facility's procedures for handling and counting narcotics were scrutinized, with staff members reporting no prior issues with narcotic counts. The investigation involved interviews with staff and a review of the facility's records, but no confirmed perpetrator was identified. The facility's failure to prevent the misappropriation of medications placed residents at risk for decreased quality of life and dignity, as well as the potential for missed doses of necessary medications.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, specifically involving inappropriate sexual touching between two residents. Resident #1, a female with severe cognitive impairment and multiple health conditions including dementia and major depressive disorder, was found in a compromising situation with Resident #2, a male with moderate cognitive impairment and a history of schizophrenia and bipolar disorder. The incident occurred when Resident #1 was found in Resident #2's room with her clothing disarranged, and Resident #2 was observed with his mouth on her breast. The records indicate that Resident #1 was tearful and indicated distress when found, although she later showed no recollection of the event. Resident #2 also claimed no memory of the incident but acknowledged the possibility of inappropriate behavior. The facility's documentation did not initially reflect any prior behaviors or incidents involving Resident #2, and his care plan was only updated after the incident to include monitoring for potential sexual behaviors. The facility's policy on abuse, which emphasizes the right of residents to be free from abuse by anyone, was not effectively implemented in this case. The incident was reported to the appropriate authorities within the facility, but the lack of preventive measures and prior identification of potential risks contributed to the occurrence of the event. The deficiency highlights a failure in the facility's responsibility to ensure the safety and protection of its residents from abuse.
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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) |
|---|---|---|---|---|
| Clarksville Nursing Home | 2 mi | ★★★★★ | 14 | 0 |
| Hill Nursing Home, Inc. | 24.4 mi | ★★★★★ | 0 | 0 |
| Heritage House At Paris Rehab & Nursing | 24.6 mi | ★★★★★ | 13 | 0 |
| Memorial Heights Nursing Center | 24.7 mi | ★★★★★ | 10 | 0 |
| Legend Healthcare And Rehabilitation - Paris | 27.2 mi | ★★★★★ | 14 | 0 |
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