Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Clarksville Health & Rehab Center during CMS and state inspections, most recent first.
Incomplete and inaccurate clinical records were found for multiple residents. One resident’s trach order documented an inner cannula change even though the resident did not use an inner cannula, two residents had side-effect monitoring orders continued after the related meds were discontinued, one resident’s weight was charted incorrectly by the RD, and another resident’s injury record contained conflicting accounts between nursing and provider documentation.
Delayed Response to Resident Call Lights: A resident’s call light for incontinence care was turned off before assistance was provided, and the resident stated she had been wet and waiting for care for a long time. Later, the resident’s call light for help moving an over-bed table remained on for about 12 minutes while staff walked by or entered the room without acknowledging the request, until a CNA finally provided assistance. Staff interviews and facility policy confirmed call lights should not be turned off until the resident receives the requested care.
The facility failed to maintain a homelike environment when residents on two units reported lukewarm or cold water that did not consistently reach a comfortable temperature, and staff acknowledged ongoing water temperature problems and prior heater repairs. The facility also failed to keep a dining room fish aquarium clean and sanitary; observations showed algae buildup, food particles, and corrosion-like material, while staff gave inconsistent responsibility for cleaning and stated there was no policy for the aquarium.
Unsafe Water Temperatures: Water temperatures on two units were found to be too hot, with several resident rooms noted during observation and later measurements showing 125.1 degrees and 129.4 degrees. An LPN said there had been a prior problem that had to be fixed, residents reported inconsistent hot water, and the maintenance director stated the risk was potential scalding. The Administrator reported there was no policy for water temperatures.
Failure to Monitor Bloody Urine and Notify Provider: A resident with an indwelling urinary catheter was documented as having bloody urine, but the RN only noted that she would continue to monitor. The record did not show a follow-up note or documentation that the MD was notified of the change in condition. Staff interviews confirmed that new blood in urine should be reported to the MD and communicated to the next shift.
A resident at high risk for pressure ulcers developed a stage 3 ulcer due to the facility's failure to implement preventive measures. Despite being identified as high risk, necessary interventions like pressure-reducing devices and a turning program were not in place. The resident's condition worsened, requiring debridement, highlighting a lack of adherence to the facility's skin and wound care policies.
A resident with a right hip fracture experienced untreated pain on multiple occasions due to the facility's failure to communicate and document pain management effectively. Despite therapy staff documenting severe pain, there was no evidence of communication with nursing or interventions to address the pain. The facility's inconsistent administration of pain medication further contributed to the resident's untreated pain, adversely affecting their physical functioning.
The facility allowed CNAs to apply a zinc topical cream to residents without a physician's order, which is outside their scope of practice. This was observed on three nursing units, and none of the residents had orders for the cream. The DON was unaware of the zinc content in the barrier cream being used, and facility policies did not specify who could administer such treatments.
A facility failed to conduct a thorough investigation into a resident's injury of unknown origin, lacking complete documentation and accurate pain assessments. The investigation summary did not align with therapy notes indicating significant pain, and essential staff and resident interviews were missing. The facility's actions did not meet the requirements for past noncompliance.
A resident's comprehensive admission MDS assessment was not completed in a timely manner, as required by the RAI manual. The assessment, due within 14 days of admission, was delayed due to staffing changes and EHR software issues, and was completed 22 days late. Facility staff confirmed the delay and acknowledged the guidelines for assessment timing.
A resident's baseline care plan was not developed within the required 48 hours of admission, delaying the provision of person-centered care. The plan, when created, lacked specific details on the resident's daily care needs. Facility staff acknowledged the issue, citing limitations of the electronic health system.
The facility staff failed to maintain complete and accurate clinical records for two residents. One resident's x-ray results, indicating a right femoral neck fracture, were missing from the chart, while another resident's skin assessments were inaccurately documented, leading to discrepancies in care. These issues were identified during a survey and reported to the facility's DON and corporate staff.
Incomplete and Inaccurate Clinical Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for multiple residents. For one resident with diagnoses including peripheral vascular disease, vocal cord paralysis with tracheostomy, diabetes, hypertension, anemia, atrial fibrillation, depression, anxiety, schizophrenia, and bradycardia, the chart contained a physician order to change a tracheostomy inner cannula every three months even though the resident did not have or use an inner cannula. The treatment record documented inner cannula changes on multiple dates, but during observation and interviews the resident and LPN stated the tracheostomy did not have an inner cannula and that the tube itself was changed every three months. The DON also stated the order needed to be clarified because the resident had never had or used an inner cannula. For two residents with severe cognitive impairment, the clinical record continued to show monitoring for medication side effects after the medications had been discontinued. One resident with dementia, Alzheimer’s disease, atrial fibrillation, hypertension, generalized anxiety disorder, and diabetes had risperidone discontinued, but the order to monitor for side effects remained active and nursing documentation continued every shift for several months afterward. Another resident with dementia, mood disorder, atrial fibrillation, and major depressive disorder had Zoloft discontinued, but the side-effect monitoring order also remained active and nursing documented continued monitoring every shift for several months after discontinuation. An LPN stated it would not be indicated to continue monitoring for side effects of medications that had been discontinued. The facility also documented inaccurate resident information and conflicting event details in other records. For one resident, the RD recorded a weight of 119 lbs. on a nutritional therapy observation document even though the resident’s weight record showed 219 lbs. and a reweight of 229 lbs. For another resident with severe cognitive impairment and diagnoses including recent stroke, vascular dementia, type 2 diabetes, morbid obesity, and moderate protein-calorie malnutrition, the record contained conflicting descriptions of a September 2024 injury event. Nursing documentation stated the resident hit an elbow while being weighed with a Hoyer lift, while a provider note described the resident being assisted with a gait belt, lowered to the floor after the legs buckled, and then sustaining a right humerus fracture. The administrator later gave a different account, and no witness statements were available for review.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of Resident #76 by not responding to call lights in a timely manner and by turning off call lights before the resident’s requested assistance was provided. During observation, Resident #76 activated her call light for incontinence care, but a CNA only entered to pick up the lunch tray and said she would return, and then an RN turned off the call light without determining the resident’s needs or ensuring care had been provided. When interviewed shortly afterward, Resident #76 stated she had not received any care yet and was wet and needed changing for a long time. Later, Resident #76 activated the call light again for help moving her over-bed table, and the call light remained on for approximately 12 minutes before assistance was provided. Two staff members entered the room without acknowledging the call light or offering assistance, and several employees were observed walking by without responding. A CNA eventually entered to pick up the breakfast tray, acknowledged the call light, and provided assistance. Staff interviews confirmed that call lights should not be turned off until the resident receives the requested care or assistance, and facility policy stated that residents’ requests should be responded to and that promised assistance should be provided promptly.
Unsafe Water Temperatures and Unclean Aquarium
Penalty
Summary
The facility failed to maintain a homelike environment on two units by not providing consistent hot water for residents. During observations in resident rooms on the Sundrop and [NAME] Lane units, water in the bathrooms never reached a comfortable temperature and remained only lukewarm after running for several minutes. An LPN on the Sundrop unit confirmed there had been a prior problem with the water that had required repair, and a CNA stated the water on the Sundrop unit does not get hot, so she runs faucets to let the water warm up before giving baths and sometimes has to get hot water from the spa. A resident stated the water only gets warm, not hot, and takes a long time to warm up, and multiple residents in council reported that the water never gets hot or sometimes gets hot suddenly. The maintenance director stated he wanted water temperatures maintained between 105 and 120 degrees and acknowledged that one hall had trouble reaching temperature and that a contractor was coming to research the problem; he also reported that several months earlier a water heater had been taken offline for about a week for repairs. The facility also failed to keep the fish aquarium in the dining room on the 400 nursing unit clean and sanitary. Observations showed the aquarium glass was black with algae-like material, the fish could not be seen, and the top of the tank had food particles with corrosion-like material on the motor/filter. An LPN stated she tried to keep it clean and cleaned it about once a month, fed the fish, and vacuumed the rocks, but directed questions about responsibility to the Administrator. The Administrator stated the LPN was supposed to be in charge of cleaning the aquarium and that she would buy supplies when requested. A later observation showed the aquarium had been removed from the dining room area, and the Administrator stated there was no policy for cleanliness or home-like environment related to the fish aquarium.
Unsafe Water Temperatures
Penalty
Summary
The facility failed to maintain an environment free of accident hazards regarding water temperatures on two units, Sundrop and [NAME] Lane. During observations on 6/10/26 at 8:37 AM, several resident rooms were noted to have water temperatures that were too hot for a hand to be held under. Later that morning, an LPN on the Sundrop unit confirmed awareness that there had been a problem with the water temperature previously and that someone had to come in and fix it. During the resident council group interview at 1:30 PM, multiple residents stated that the water never gets hot and other times gets hot just like that. During a facility tour at 4:17 PM with the maintenance director, water temperatures were checked at various points in the facility. The maintenance director stated he wanted hot water temperatures between 105 and 120 degrees. Water in an unoccupied room measured 125.1 degrees, and another room measured 129.4 degrees. The maintenance director stated that the higher temperature was a little warm and identified potential scalding as the risk. At the end-of-day meeting, the Administrator and DON were informed of the findings, and the Administrator stated they had adjusted and turned the water temperature down. When asked for a policy regarding water temperatures, the Administrator reported there was no policy.
Failure to Monitor Bloody Urine and Notify Provider
Penalty
Summary
The facility failed to ensure appropriate monitoring and assessment of a change in condition related to a urinary catheter for one resident, Resident #156, when hematuria was observed. On 1/1/26 at 1:38 PM, a registered nurse documented that the resident was lying in bed moaning and groaning, was given PRN pain medication, had stable vital signs, and that the catheter was draining bloody urine; the note stated the nurse would continue to monitor. The record did not contain a follow-up note after that entry and did not contain documentation that the medical doctor was notified of the bloody urine. During interviews, RN1 stated that if blood was observed in a resident's urine and it was a new finding, the doctor should be notified, and if a note says to monitor, a follow-up note would be expected. RN3 stated that if blood in the urine was observed, she would report it to the doctor, follow the doctor's instructions, report it to the next shift, and document that the report was given to the oncoming shift to monitor. Facility documentation reviewed included the Indwelling Urinary Catheter Care Procedure and the Resident Change in Condition Policy, which addressed catheter care and notifying the physician/provider for significant changes in condition. Resident #156 was later sent to the hospital and did not return to the facility.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility staff failed to provide adequate care and services to prevent the development of a pressure ulcer for a resident, resulting in harm. The resident, who was admitted with multiple diagnoses including cerebral infarction and diabetes, was identified as being at high risk for pressure ulcer development based on the Braden scale assessments. Despite this, the facility did not implement necessary interventions such as pressure-reducing devices or a turning and repositioning program until after the pressure ulcer had developed and worsened. The resident's clinical records and staff interviews revealed that the facility did not document any skin issues upon admission, and the baseline care plan did not address potential skin breakdown. The resident's condition deteriorated, leading to the development of a stage 3 pressure ulcer on the sacrum, which required debridement. The facility's failure to implement preventive measures, despite the resident's high-risk status, contributed to the development and worsening of the pressure ulcer. Interviews with facility staff, including LPNs and the wound treatment nurse, confirmed that standard care practices such as turning and repositioning and the use of barrier creams were not adequately documented or implemented as preventive measures. The facility's policies on skin and wound care and pressure injury prevention were not followed, and there was a lack of evidence of any additional measures being put in place for the resident, who was completely dependent on staff for care.
Failure to Manage Resident's Pain Leads to Harm
Penalty
Summary
The facility staff failed to provide adequate pain management for a resident with a right hip fracture, resulting in numerous instances of untreated pain. The resident, who had a history of cerebral infarction and muscle weakness, was admitted with a right hip fracture of unknown origin. Despite documented complaints of unrelieved pain on 12 occasions, the facility staff did not respond appropriately, adversely affecting the resident's physical functioning in therapy. The resident's pain was documented by occupational and physical therapy staff on multiple occasions, with pain levels reaching severe intensity. However, there was no evidence that the pain was communicated to nursing or the provider, nor were any interventions documented to address the pain. The facility's medication administration record showed that pain medication was administered inconsistently and did not align with the times therapy documented the resident's pain. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's pain and changes in condition. The Director of Nursing and the acting administrator acknowledged the expectation for staff to report incidents and assess residents for pain, but there was no documentation to support that this was done. The failure to assess and manage the resident's pain constituted harm and was identified as a deficiency during the survey.
Improper Application of Zinc Cream by CNAs Without Physician Orders
Penalty
Summary
The facility staff failed to adhere to professional standards of practice by allowing nursing assistants to apply a zinc topical cream to residents without a physician's order, which is outside their scope of practice. This deficiency was observed on three of the six nursing units. During the clinical record review, it was noted that none of the sampled residents had physician orders for the application of barrier cream. Interviews with various staff members, including LPNs and CNAs, revealed a lack of awareness regarding the necessity of a physician's order for the application of zinc oxide cream, which was being used as a barrier cream. The facility's director of nursing was unaware that the barrier cream currently in use contained 21% zinc oxide and was being applied by CNAs. The facility's policy on medication administration did not specify who is permitted to administer medications and/or topical creams, contributing to the oversight. The director of nursing acknowledged the issue when informed by the surveyors, but no additional information or corrective actions were provided in the report.
Incomplete Investigation of Resident Injury
Penalty
Summary
The facility staff failed to conduct a complete and accurate investigation into an injury of unknown origin affecting a resident with severely impaired cognition. The investigation lacked thorough documentation, including missing staff and resident interviews, and discrepancies in the reported pain levels of the resident. The facility's final investigation summary inaccurately reflected the resident's pain levels during therapy sessions, as documented in occupational therapy notes, which indicated significant pain that was not captured in the investigation summary. Additionally, the investigation folder contained only three staff interviews, with two being from the same staff member, and no resident interviews, despite claims of comprehensive interviews being conducted. The facility's investigation was further compromised by the absence of relevant documentation and assessments. The acting administrator admitted to assuming interviews were conducted but could not provide evidence, instead offering quarterly nursing assessments that predated the investigation period. Interviews with the resident's spouse and the resident herself revealed conflicting accounts of the resident's pain and injury history. The facility's policy on resident abuse, which outlines the need for immediate reporting and comprehensive assessments, was not adhered to, as evidenced by the lack of a full body assessment and pain management for the resident. The facility's failure to provide accurate and complete documentation and investigation findings resulted in the deficiency not meeting the requirements for past noncompliance.
Delayed MDS Assessment for Resident
Penalty
Summary
The facility staff failed to complete a comprehensive admission Minimum Data Set (MDS) assessment in a timely manner for one resident, identified as Resident #3 (R3), in a survey sample of five residents. R3 was admitted to the facility, and the MDS assessment with an assessment reference date of April 14, 2024, was not completed and signed until May 6, 2024, by a registered nurse (RN #1). According to the Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the MDS completion date should be no later than the 14th calendar day of the resident's admission. This delay was confirmed during an interview with RN #1 and RN #2, who acknowledged that the assessment should have been completed by April 21, 2024. The delay in completing the MDS assessment was attributed to an unexpected and unanticipated change in staffing within the MDS department, as well as a change in the electronic health record (EHR) software, which caused additional delays. During interviews, the facility's acting administrator, director of nursing, and corporate staff were made aware of these findings. The facility administration stated that they follow the RAI manual for guidelines on the timing of assessments, but no specific facility policy regarding the timeliness of assessments was provided.
Failure to Develop Timely Baseline Care Plan
Penalty
Summary
The facility staff failed to develop and implement a baseline care plan for a resident within the required 48 hours of admission. The resident was admitted for skilled or long-term care, but the baseline care plan was not developed until several days later. This delay in creating the care plan meant that the necessary instructions to provide effective and person-centered care were not available to the staff in a timely manner. The baseline care plan, when eventually developed, included various care needs such as anticoagulation therapy, behavioral needs, cultural preferences, diet, fall prevention, medication monitoring, pain management, safety, skin care, social services, and therapy. However, it did not provide specific details on the level of support needed or the interventions being provided for the resident's daily care needs. During interviews, the registered nurses responsible for the Minimum Data Set (MDS) assessments explained that the admitting nurse or unit managers are tasked with completing the baseline care plan. They acknowledged that the new electronic health system used by the facility did not provide detailed information on the resident's needs. The facility's policy requires the development and implementation of a baseline care plan within 48 hours of admission, but this was not adhered to in this case. The facility administration, including the acting administrator and director of nursing, were informed of these findings during meetings with the surveyors.
Incomplete and Inaccurate Clinical Records for Two Residents
Penalty
Summary
The facility staff failed to maintain a complete and accurate clinical record for two residents, leading to deficiencies in their care. For Resident #2, the staff did not include the results of an x-ray in the clinical record. The nurse practitioner had ordered an x-ray for the resident's right hip due to complaints of pain, but the results, which showed a right femoral neck fracture, were not documented in the resident's chart. This omission occurred despite the facility's investigation file containing a copy of the x-ray. The resident was subsequently sent to the emergency department for evaluation and returned to the facility for conservative nonsurgical treatment. For Resident #3, the facility staff failed to maintain accurate skin assessments in the clinical record. The nurse practitioner noted an abrasion on the resident's coccyx, but a subsequent weekly skin observation incorrectly reported no skin issues. A late entry was later made, documenting an open area on the sacrum, which was identified by a CNA. The wound treatment nurse confirmed the skin impairment on the same day. These discrepancies in documentation were brought to the attention of the facility's director of nursing and corporate staff during an end-of-day meeting.
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.
Illustrative
What surveyors actually found near you
We read the 41 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — 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) |
|---|---|---|---|---|
| Chase City Health And Rehab Center | 13.6 mi | ★★★★★ | 0 | 0 |
| Berry Hill Nursing Home | 19.8 mi | ★★★★★ | 0 | 0 |
| Oxford Health And Rehabilitation Center | 20.4 mi | ★★★★★ | 15 | 0 |
| Brantwood Nh & Retirement Center | 20.4 mi | ★★★★★ | 4 | 0 |
| South Boston Health & Rehab Center | 20.8 mi | ★★★★★ | 1 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Clarksville Health & Rehab Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.