Clarksville Nursing Center

Inspectors wroteBased on record review, resident and staff interviews and observations, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 3 of 15 (Resident #1, Resident #2, Resident #3) reviewed for environment, in that: The facility failed to ensure water temperatures in the resident showers in 2 of 3 of the facility communal showers located on 100 hall and 300 hall was kept at a comfortable temperature for residents. The third shower, located on 200 hall, was inoperable due to construction. This could place residents at risk of unsanitary or uncomfortable conditions by not having hot water available for showers.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 4 of 5 residents (Resident #2, Resident #7, Resident #8, and Resident #11) reviewed for trauma-informed care. The facility did not ensure the care plans of Resident #2, Resident #7, Resident #8, and Resident #11, who had histories of trauma, identified possible triggers and interventions. This failure could place residents at an increased risk for severe psychological distress due to re-traumatization.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that it was free from a medication error rate of 5 percent or greater. The facility had a medication error rate of 8.82 %, based on 3 errors out of 34 opportunities, which involved 3 of 5 residents (Residents #15, #26, and #27) reviewed for medication administration. 1. The facility failed to ensure LVN K administered insulin correctly for Resident #15. 2. The facility failed to ensure RN B administered Aspirin 325 mg (a common strength of the nonsteroidal anti-inflammatory drug (NSAID) used for pain/fever relief (headaches, colds, arthritis) and, at the doctor's direction, for heart/stroke prevention by reducing blood clots) as ordered by the physician for Resident #26 on 12/08/25. 3. [...]

Inspectors wroteBased on observations, interviews, and record reviews, 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. The facility failed to ensure dietary staff provided food that was palatable and had an appetizing temperature on 12/09/25. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety for 1 of 1 kitchen reviewed. The facility did not ensure:1. Food items were labeled and dated.2. Hair restraints were worn. 3. The kitchen staff had a Soap dispenser located in a place that did not prevent the staff contaminating the clean dish rack. These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents the right to participate in the development and implementation of his or her person-centered plan of care for 1 of 6 residents (Resident #47) reviewed for care plans. The facility failed to invite and include the input of Resident #47 and/or the resident's representative as members of the interdisciplinary team in Care Plan Conference meetings. This failure could place residents at risk of not receiving the interventions, treatments, and care necessary for the resident to reach their highest practicable physical, mental, and psychosocial well-being by not involving the resident and/or the resident's representative in Care Plan Conference meetings.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 2 of 3 residents (Residents #15 and #19) reviewed for Medicare/Medicaid coverage. 1. The facility failed to ensure Resident #15 was given a NOMNC (is a notice that indicates when your care is set to end from a skilled nursing facility when discharged from skilled services prior to his covered days being exhausted. 2. The facility failed to ensure Resident #19 was given a SNF ABN when discharged from skilled services at the facility prior to covered days being exhausted. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's mental, nursing, and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #1) reviewed for care plans. The facility failed to fully develop a comprehensive person-centered care plan that was specific for Resident #1 to address the resident's communication deficit. This failure could place residents at risk for not getting their medical, physical, and psychosocial needs met and not being provided with the necessary care or services and having personalized plans developed to address their specific needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish based on the comprehensive assessment and consistent with the resident's needs and choices for 1 of 2 residents (Resident #48) reviewed for activities of daily living. The facility failed to provide communication assistance to effectively communicate with staff for Resident #48. This failure could place residents at risk for decline and diminished quality of life.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status and is offered sufficient fluid intake to maintain proper hydration and health for 2 of 5 residents (Resident #13 and Resident #19) reviewed for nutrition. 1. The facility failed to ensure Resident #13 had water in his cup to drink on 12/08/25 and 12/09/25. 2. The facility did not ensure Resident #19 was given a shake as ordered by the physician. This failure could place residents at risk for decreased nutritional status, decline in health, serious illness, or hospitalization.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that residents were free of significant medication errors for 1 of 1 resident (Resident #15) reviewed for insulin administration. The facility did not ensure LVN K administered Resident #15's Novolog (insulin medication) according to the manufacturer's instructions on 12/08/25. This failure could place residents at risk of medical complications and prevent them from receiving the therapeutic effects of their medications.

Inspectors wroteBased on observation and interview the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly for 1 of 25 residents (Resident #11) observed for medication storage. 1. The facility failed to ensure Resident #11 did not have hydrocortisone cream and Neosporin on his bedside table and dresser. These failures could place residents at risk for not receiving drugs and biologicals as needed, or overmedicating, .

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals for 1 of 5 (Resident #19) residents reviewed for special eating equipment and assistance when consuming meals. The facility failed to ensure Resident #19 had a physician's ordered cup with lid for drinking fluids. This failure could place residents at risk for harm by weight loss, diminished independence, and self-esteem.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #13) room reviewed for infection control practices and enhanced barrier precautions. 1) The facility failed to ensure the Treatment nurse used the proper handwashing technique while providing wound care for Resident #13. 2) The facility failed to ensure the Treatment Nurse disinfected her scissors during wound care when she cut the dirty dressing and then cut the clean dressing with the contaminated scissors. These failures could place residents at increased risk for serious complications from a communicable disease that could diminish the residents' quality of life.

Inspectors wroteBased on interview, and record review the facility failed to treat each resident with respect and dignity that promoted maintenance or enhancement of quality of life for 1 of 14 residents reviewed for resident rights. (Resident #12) 1. The facility failed to treat Resident #12 with dignity and respect witnessed by Resident #43 when CNA D told Resident #12 Oh no ma'am, we are not fixing to do this because I am not going to be the one on 03/25/24 with an attitude and rude tone . These failures could place residents at risk for decreased quality of life, decreased self-esteem and increase anxiety.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 6 residents (Resident #24) reviewed for PASRR Level I screenings. 1. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #24. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (PTSD with an onset date of 04/16/21) was present upon Resident #24's re-admission date on 05/17/2024. 2. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #24. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, after a new diagnosis of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), with an onset date of 08/28/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 6 residents reviewed for care plans. (Resident #28) The facility failed to implement Resident #28's signed physician order dated 03/31/2024 for occupational therapy to evaluate Resident #28 for a coffee lid. This failure could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 of 2 residents (Resident #147) reviewed for respiratory care and services. The facility failed to change the filter on an oxygen concentrator machine that were in use for Resident #147 on 09/16/24. This failure could place residents at risk for developing respiratory complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen and the facility's only dining room. The facility failed to ensure that a canister of oatmeal was closed properly in an airtight container after opening. The facility failed to ensure that dirty rags were stored in proper containers prior to being taken to the laundry. The facility failed to ensure that the walls and floors inside the kitchen were properly cleaned. The facility failed to ensure the toaster was cleaned after each use per facility protocol. The facility failed to ensure that trash was properly disposed of. The facility failed to ensure that the kitchens fryer was properly cleaned and the oil changed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 2 of 13 resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) and 1 of 1 dining room reviewed for physical environment. 1. The facility did not ensure room [ROOM NUMBER] had clean floors and walls. 2. The facility did not ensure the bathroom in room [ROOM NUMBER] had no holes and the sheetrock was in good repair. 3. The facility failed to repair scratches in the paint on the wall behind the head of the bed and on the wall next to the bed in room [ROOM NUMBER]A. 4. The facility failed to ensure the wallpaper in the dining room was in good repair. This failure could place the residents at risk for decreased quality of life and infection due to unsanitary conditions.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the meals served to residents met the nutritional needs of residents for 1 of 1 meal (the lunch meal), as evidenced by: The facility failed to ensure [NAME] F followed the menu for the lunch meal on 08/14/23. The facility failed to ensure [NAME] F followed the recipe for pureeing the hamburger beef patty for the lunch meal. These failures could place residents at risk for weight loss, not having their nutritional needs met, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 10 residents (Resident's #10, Resident # 21, and Resident # 46) reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #10, Resident #21, and Resident #46 who complained the food was served cold and did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 7 of 8 meetings (January 2023, February 2023, March 2023, April 2023, May 2023, June 2023, July 2023, and August 2023) reviewed for QAPI. The facility did not ensure the DON attended their QAPI meeting in August 2023. The facility did not ensure the Infection Preventionist attended their QAPI meetings in March 2023 and April 2023. The facility did not ensure the Medical Director attended their QAPI meetings in January 2023, February 2023, April 2023, June 2023, and July 2023. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free from pests in 1 of 1 dining room, 1 of 1 kitchen for pest control. The facility did not maintain an effective pest control program to ensure the facility was free of flies. This failure could place residents at risk for an unsanitary environment and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive resident-centered assessment of each resident's cognitive, medical, and functional capacity in a timely manner for 1 of 13 residents (Resident #14) reviewed for accuracy of assessments. The facility failed to complete Resident #14's admission MDS assessment within 14 days of admission. This failure could place residents at risk of not having their needs met.

Inspectors wroteBased on interview, and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 1 of 6 residents (Resident #14) reviewed for PASRR. The facility failed to ensure Resident #14's PASRR Level 1 Screening indicated a diagnosis of mental illness. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to develop or implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 13 residents reviewed for care plans. (Resident #6) The facility did not develop or implement a comprehensive care plan to address Resident #6's diagnosis of PTSD (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations) and history of trauma. This failure could place residents at risk for inaccurate care plans and decreased quality of care.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure necessary services to maintain personal hygiene were provided for 1 of 47 residents reviewed for ADLs. (Resident #11). The facility did not ensure Resident #11 received fingernail care. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 2 residents' (Resident #6) reviewed for trauma-informed care. The facility did not ensure Resident #6 had an accurate trauma screen that identified possible triggers when Resident #6 had a diagnosis of PTSD (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations). [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 2 of 6 residents (Resident #43, #45) reviewed for medication administration. 1. The facility did not ensure Resident #43 rinsed and spit after administration of an inhalation medication (Breo Elipta) for a diagnosis of COPD. 2. Resident #43 was not given a multivitamin tablet as prescribed by the physician. 3. Resident #45 was not given senna 8.6mg (laxative) as prescribed by the physician. This failure could place residents at an increased risk for inaccurate drug administration and not receiving the care and services to meet their individual needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 3 errors out of 25 opportunities, resulting in a 12 percent medication error rate for 2 of 6 residents reviewed for medication error. (Resident #43, Resident #45) The facility failed to ensure the following: 1. Resident #43 rinsed and spit after administration of an inhalation medication (Breo Elipta). 2. Resident #43 was given a multivitamin tablet as prescribed by the physician. 3. Resident #45 was given senna 8.6mg (laxative) as prescribed by the physician. These failures could place residents at risk for inaccurate drug administration.