Clarksville Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Clarksville Health & Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF686Jun 19, 2024

  Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to provide care and services to ensure residents received care to prevent development of pressure ulcer(s) for one resident (Resident # 3- R3) in a survey sample of 5 residents, resulting in harm for R3. Findings included: For R3, the facility staff failed to implement interventions to prevent the development of and failed to identify and treat a pressure injury until at an advanced stage of wound deterioration, requiring sharps debridement (cutting the dead tissue out), which constituted harm. Review of the clinical record was conducted on 6/17/2024 -6/18/2024 and 6/20/2024. […]

• Actual harm, isolatedF697Jun 19, 2024

  Based on staff interviews, resident interviews, clinical record and facility documentation, the facility staff failed to provide pain management, resulting in numerous instances of untreated pain, which constituted harm for one resident (Resident #2 - R2), in a survey sample of five residents. The findings included: For R2, who had a right hip fracture of unknown origin, the facility staff failed to respond to and treat the resident's documented complaints of unrelieved pain on 12 occasions, which adversely affected her level of physical functioning in therapy and constituted harm. Resident #2 (R2) was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF812Jun 11, 2026

  Based on observation, staff interview, and facility documentation review, the facility staff failed to store, prepare, and serve food in accordance with food safety standards in the main kitchen, which had the potential to affect residents on all six units. The findings included:On 6/9/26 at 12:27 pm, initial observations of the kitchen and food storage areas were conducted with the Food Services Director (FSD).In the dry storage area there was a package of Jello mix which had a labeled open date of 4/3/26 and a use by date of 5/3/26, which was available for use. In the walk-in cooler there was a tray with a lid that appeared to have a food product that was red in color and jelly like consistency. The label on the container appeared old and was not legible. […]

• No harm, potential for more than minimal, patternF842Jun 11, 2026

  Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for five of thirty-six residents in the survey sample (Residents #5, #6, #12, #14 and #152). The findings include: 1. Resident #5's clinical record documented a tracheostomy inner cannula was changed once every three months when the resident did not have/use an inner cannula. Resident #5 (R5) was admitted to the facility with diagnoses that included peripheral vascular disease, history of vocal cord paralysis with tracheostomy, diabetes, hypertension, anemia, atrial fibrillation, depression, anxiety, schizophrenia and bradycardia. […]

• No harm, potential for more than minimal, patternF658Jun 19, 2024

  Based on observation, staff interview, and facility documentation review, the facility staff failed to provide care to residents within the professional standards of practice and within the scope of practice of staff providing care for residents on 3 of 6 nursing units. The findings included: For residents on 3 of the 6 nursing units, the facility staff permitted nursing assistants to apply a zinc topical cream to residents, which was outside of their scope of practice and without a physician order. On 6/17/24-6/18/24, during the clinical record review of the residents sampled (Resident #1-Resident #5), it was not noted that any of the residents had physician orders for the application of barrier cream. […]