Clarksville Nursing Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Aug 16, 2023

  Based 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. […]

• No harm, potential for more than minimal, patternF921Apr 14, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF699Dec 10, 2025

  Based 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.Record review of Resident… […]

• No harm, potential for more than minimal, patternF759Dec 10, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF804Dec 10, 2025

  Based 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.Findings included: During a confidential resident group meeting 9 residents stated the food was lousy and cold. During an observation and interview on 12/09/25 at 12:16 p.m., lunch tray was sampled by the Dietary Manager and six surveyors. […]