Signature Healthcare of Clarksville

In the surveyor’s words

From the most serious findings on record at Signature Healthcare of Clarksville, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 28, 2025

  Based on policy review, fall investigation review, medical record review, observation, and interview, the facility failed to ensure a safe and secure environment for 5 of 7 (Resident #31, #50, #248, #498 and #501) sampled residents reviewed for falls and accidents. The facility failed to ensure processes were implemented to provide supervision and assistance to ensure the residents' environment was free of accident hazards. The facility failed to conduct thorough fall investigations to identify all contributing factors (root causes) and failed to implement appropriate interventions to ensure resident safety. Resident #498 was admitted on [DATE] and had 13 falls from [DATE] through [DATE]. […]

• No harm, potential for more than minimal, patternF655May 26, 2023

  Based on policy review, medical record review, and interview, the facility failed to provide an accurate Baseline Care Plan for 4 of 4 sampled residents (Resident #1, #2, #3 and #4) reviewed with Baseline Care Plans. The findings include: 1. Review of the facility's policy titled, Baseline Care Plan Policy, effective date 9/23/2022, revealed .Complete a Baseline Care Plan to promote continuity of care and communication among nursing home stakeholders, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission .Baseline Care Plan will be working tool for the first 48 hours . […]

• No harm, potential for more than minimal, patternF656May 26, 2023

  Based on policy review, medical record review, observation, and interview, the facility failed to provide an accurate and revised Comprehensive Care Plan for 4 of 4 sampled residents (Resident #1, #2, #3 and #4) reviewed with Comprehensive Care Plans. The findings include: 1. Review of the facility's policy titled Comprehensive Care Plans, effective date 4/6/2015 and revised 7/19/2018, revealed .A person-centered Comprehensive Care Plan that includes a measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. […]

• No harm, potential for more than minimal, patternF694May 26, 2023

  Based on policy review, medical record review, observation, and interview the facility failed to follow professional standards of practice of Peripherally Inserted Central Catheter (PICC) Infusion therapy, medication administration, and obtain Physicians Orders for 3 of 3 sampled residents (Resident #1, #3 and #4) with a PICC line. The findings include: 1. Review of the facility's policy titled, Vascular Access Devices and Infusion Therapy Procedures Maintaining Patency of Peripheral and Central Vascular Access Devices IV [Intravascular] Flush Policy and Procedure, dated 2011, revealed .Purpose to maintain the patency of all peripheral and central vascular access devices [VADs] .Vascular access devices are flushed after each infusion to clear the infused medication from the catheter lumen. […]

• No harm, potential for more than minimal, isolatedF550May 28, 2025

  Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services to promote dignity for 1 of 5 (Resident #36) sampled residents reviewed for activity of daily living (ADL) care when they failed to provide hair care. The findings include: 1. Review of the facility policy titled, Resident Rights, dated 1/31/25, revealed .All residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility .All residents will be treated in a manner and in an environment that promotes maintenance and enhancement of quality of life. […]