Clarksville Skilled Nursing & Rehab Center

In the surveyor’s words

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

• Actual harm, isolatedF805Jul 10, 2025

  Based on observations, interviews, and record review, the facility failed to follow Doctor's Orders for 2 out of 3 residents reviewed (Resident #2 and Resident #3). Resident #2 had an order for a mechanical soft diet with ground meat. Resident #2 received cut up sausage links instead of ground up sausage for breakfast. Resident #2 had a coughing/choking spell and five days later they admitted to the hospital with aspiration pneumonia. Resident #3 had an order for cut up meat. The kitchen staff prepared to serve Resident #3 a cheeseburger without cutting the meat cut up, as ordered by the Doctor. The facility reported a census of 34 residents.Findings include:1. […]

• No harm, potential for more than minimal, patternF812Jan 4, 2023

  Based on observation, policy review and staff interview the facility failed to measure total volume of prepared pureed food to determine an appropriate serving size for 2 of 2 residents (Resident #3 and #16), failed to perform temperature check on food served to Resident #18 and #25, failed to properly reheat food to 165 degrees Fahrenheit (F) that was served out to 1 of 2 resident (Resident #16) and failed to prevent bare hands from coming into contact with food. The facility identified a census of 29 residents. Finding include: During an interview on 12/29/22 at 10:26 a.m. Staff A, Dietary Cook, reported they had two residents on pureed diets and she would be preparing three servings of puree for each menu item. A Fall/Winter 2021-2022 Week 3 Dinner general pureed menu: a. […]

• No harm, potential for more than minimal, isolatedF628Apr 9, 2026

  Based on the electronic health record review, the Notice of Transfer Form to Long Term Care Ombudsman form review and staff interviews, the facility failed to include 1 out of 3 residents reviewed for Ombudsman Notification (Resident #1). In addition, the facility failed to complete a recapitulation of resident's stay (discharge summary) for 1 of 1 residents reviewed (Resident #41). The facility reported a census of 36 residents.Findings include: 1. Resident #1's Census documented discharged to the hospital on 2/28/26 and returned to the facility on 3/3/26. The February 2026 Notice of Transfer Form to Long Term Care Ombudsman (LTCO) form didn't include Resident #1. […]

• No harm, potential for more than minimal, isolatedF580Jul 10, 2025

  Based on interviews, observations, record and policy review, after the facility identified a change in a resident's condition, the facility failed to notify a resident's family or responsible party for 1 of 3 residents reviewed (Resident #1). After staff heard the door alarm sound, they found Resident #1 attempted to exit the building, opened a door and was outside on the sidewalk. The facility didn't notify Resident #3's wife of the incident until days later. The facility reported a census of 34 residents.Findings include: Resident #1's Minimum Data Set, dated [DATE], identified a Brief Interview for Mental Status documented a score of 11 out of 15, indicating moderately impaired cognition. Resident #1 used a wheelchair for mobility. […]

• No harm, potential for more than minimal, isolatedF641Apr 3, 2025

  Based on record review, staff interviews and Resident Assessment Instrument (RAI) Manual the facility failed to accurately document and submit accurate resident Minimum Data Set (MDS) assessments for 2 of 12 residents reviewed (Resident #15 and Resident #18). The facility reported a census of 35 Residents. Findings include: 1. Resident #15's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of hypertension (high blood pressure), diabetes, and anemia (low blood iron). […]