Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Clarksville Skilled Nursing & Rehab Center during CMS and state inspections, most recent first.
Missing Ombudsman Notification and Discharge Summary Documentation: The facility failed to include a resident on the LTCO transfer/discharge report after a hospital transfer and return, even though the EHR was expected to pull discharged residents automatically. The facility also lacked a discharge summary for another resident after discharge, and the DON acknowledged the summary was not completed as required by policy.
A resident did not receive food prepared in a form that met their individual needs, as the facility did not consistently modify meals to accommodate specific dietary requirements or physical abilities.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes, resulting in a breakdown of required communication.
A dietary cook was observed handling ready-to-eat crackers with bare hands and returning them to a container, instead of using utensils or gloves as required by facility policy. The dietary manager confirmed witnessing these actions and acknowledged that proper procedures were not followed, resulting in improper food handling during a meal service.
Two residents had inaccurate MDS assessments: one resident's new diagnosis of atrial fibrillation and use of an anticoagulant were omitted from the MDS despite supporting documentation, and another resident was incorrectly coded as using bed rails as a restraint, contrary to care plan details and RAI Manual guidance. The DON confirmed both errors and noted the facility follows the RAI Manual for MDS completion.
A resident with severe cognitive impairment and multiple diagnoses, including cancer and dementia, continued to receive gabapentin and Seroquel after hospice orders directed their discontinuation. Staff administered these medications for several days, and there was no documentation that the physician was notified of the medication error, as required by facility policy.
A pharmacist dispensed gabapentin and Seroquel to a resident despite hospice admission orders discontinuing these medications. The pharmacist, having access to the electronic health record, assumed the medications were to be continued based on prior records and did not clarify with the attending physician before dispensing, contrary to facility policy.
A resident with severe cognitive impairment and on hospice care was given gabapentin and Seroquel after orders to discontinue these medications, resulting in the resident appearing very sleepy and slumped over. Facility staff did not recognize or document the medication error, nor did they assess or notify appropriate parties as required by policy.
The facility failed to update care plans for three residents, leading to deficiencies in their care. One resident had actual pressure ulcers that were not addressed in her care plan, while two other residents were on diuretic and antipsychotic medications that were not included in their care plans. The LNHA acknowledged these oversights, which were identified through observations, interviews, and record reviews.
The facility failed to issue a bed hold notice to a resident or their representative during three separate hospitalizations. Documentation confirming the communication of the bed hold policy was not provided, despite the facility's policy requiring this discussion upon admission.
Missing Ombudsman Notification and Discharge Summary Documentation
Penalty
Summary
The facility failed to include 1 of 3 residents reviewed for Ombudsman notification on the February 2026 Notice of Transfer Form to the Long Term Care Ombudsman. Resident #1 was documented as discharged to the hospital on 2/28/26 and returned to the facility on 3/3/26, but the original LTCO report did not include the resident’s name. Staff A, the Office Assistant, stated she ran the February LTCO report early in the month and did not know why Resident #1 did not appear on the original list sent to the LTCO office. She stated the EHR system was supposed to pull the names of residents discharged monthly, and she did not manually enter the names. The facility also failed to complete a discharge summary for Resident #41, who was discharged on 2/17/26 at 1:07 PM. The resident’s EHR lacked documentation of a discharge summary with a recapitulation of the resident’s stay. The DON acknowledged that no one completed the discharge summary and stated it should have been done. The facility’s Expected/Planned Discharge policy required a discharge summary that included a recap of the resident’s stay, diagnosis, course of illness or treatment, pertinent test results, and a final summary of the resident’s status at discharge, along with a post-discharge plan of care.
Failure to Provide Food in Appropriate Form for Individual Needs
Penalty
Summary
The facility failed to ensure that each resident received food prepared in a form designed to meet their individual needs. This deficiency indicates that meals were not consistently modified or adapted to accommodate the specific dietary requirements or physical abilities of residents, such as those needing pureed, chopped, or otherwise altered food textures.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's well-being.
Improper Food Handling and Cross-Contamination During Meal Service
Penalty
Summary
During a meal service, a dietary cook was observed handling ready-to-eat food items, specifically saltine crackers, with bare hands instead of using utensils or gloves as required by facility policy. The cook used tongs to place food items such as croissants and crackers on plates, but then used her ungloved hand to adjust and touch the crackers and soup spoon, and subsequently placed touched crackers back into the container of ready-to-eat crackers. These actions were witnessed during the preparation and serving of a meal that included chicken dumpling soup, croissants, pork chop, au gratin potatoes, creamed peas, apple cranberry crunch, peaches, and milk. The dietary manager confirmed observing the cook touch the crackers with bare hands on two occasions and acknowledged that the cook should have used tongs and discarded any crackers that were touched by hand, rather than returning them to the container. The facility's food handling policy explicitly instructs staff to always use clean serving utensils and to wear gloves if hands must be used for food handling. The failure to follow these procedures resulted in improper food handling practices during the observed meal service.
Inaccurate MDS Documentation for Diagnoses, Medications, and Restraints
Penalty
Summary
The facility failed to accurately document and submit Minimum Data Set (MDS) assessments for two residents. For one resident, the MDS assessment did not include a new diagnosis of atrial fibrillation or the administration of an anticoagulant, despite the hospital discharge summary and medication administration records showing the diagnosis and medication order. The Director of Nursing confirmed that the MDS should have included the anticoagulant and that the facility did not have a specific policy for MDS completion, instead following the RAI Manual, which requires coding of diagnoses from hospital summaries and high-risk medications administered during the lookback period. For another resident, the MDS assessment incorrectly coded the use of bed rails as a restraint. The care plan indicated the resident used bilateral short side rails to assist with repositioning and care, and the Director of Nursing acknowledged that side rails should not have been coded as a restraint in this case, attributing the error to a mistake. The RAI Manual provides guidance on when to code devices as restraints, based on the resident's ability to remove them and whether they restrict movement or access to the body.
Failure to Follow Physician Orders and Notify Physician of Medication Error
Penalty
Summary
The facility failed to follow physician orders and did not notify the physician of a medication error for a resident with severe cognitive impairment, cancer, dementia, anxiety, and depression who was receiving hospice care. Hospice admission orders directed discontinuation of gabapentin and Seroquel, but staff continued to administer these medications for several days after the orders were written. Documentation showed that gabapentin and Seroquel were given on multiple occasions despite the discontinuation order. There was no documentation in the clinical record indicating that the physician was notified of the medication error. The DON reported that the error was only discovered after the resident had been discharged, and no notification to the physician occurred because the resident was no longer in the facility. The physician confirmed he was unaware of the error and had not been informed. Facility policies required accurate transcription of physician orders and prompt physician notification of medication errors, but these procedures were not followed in this case.
Pharmacist Dispensed Discontinued Medications Without Clarification
Penalty
Summary
The facility pharmacist failed to provide appropriate pharmaceutical services by dispensing medications that had been discontinued for a resident. Specifically, a resident with severe cognitive impairment, memory problems, and diagnoses including cancer, dementia, anxiety, and depression was admitted to hospice care. Upon admission, hospice orders directed the discontinuation of gabapentin and Seroquel. Despite these orders, the pharmacy delivered both medications to the facility for the resident the following day. During an interview, the pharmacist stated that he had access to the facility's electronic health record and reviewed the hospice admission orders, which did not include instructions to continue gabapentin and Seroquel. However, the pharmacist assumed these were new orders based on the resident's prior hospital records and dispensed the medications without clarifying with the attending physician, as required by facility policy. The facility's policy mandates that the pharmacist review and clarify any concerns with the attending physician before dispensing medications.
Failure to Prevent and Document Significant Medication Error
Penalty
Summary
A significant medication error occurred when a resident with severe cognitive impairment, memory problems, and diagnoses including cancer, dementia, anxiety, and depression, was administered gabapentin and Seroquel despite hospice admission orders directing these medications to be discontinued. The resident, who was receiving hospice care, continued to receive these medications for several days as documented in the Medication Administration Record. The error was discovered after the resident's family reported the resident was very sleepy and slumped over, prompting a review of the medication list by the hospice nurse and facility staff. Facility staff, including the nurse responsible for administering the medications, were unaware that a medication error had occurred until it was brought to their attention by the hospice nurse. There was no documentation in the resident's progress notes regarding the medication error, any assessment at the time of the incident, or notifications following the identification of the error. The facility's policies required accurate transcription of physician orders and documentation of actions taken in the event of medication errors, but these procedures were not followed in this case.
Failure to Update Care Plans for Medications and Pressure Ulcers
Penalty
Summary
The facility failed to revise and update care plans for three residents, leading to deficiencies in their care. Resident #8 had actual pressure ulcers on her right ankle and right buttock, identified on 2/13/24 and 1/29/24 respectively, but her care plan only addressed the risk of pressure ulcers and not the actual presence of them. The Licensed Nursing Home Administrator (LNHA) acknowledged that the care plan did not reflect the resident's current condition. Resident #13 was on a diuretic medication as per a doctor's order dated 10/27/23, but this was not addressed in her care plan. Similarly, Resident #30 was on an antipsychotic medication as per a doctor's order dated 2/20/24, but this was also not included in her care plan. The LNHA admitted that the care plans for these residents did not address their specific medication needs. The facility's Comprehensive Care Plan Policy requires that care plans be revised based on assessments and changes in the resident's health status or care needs. However, this policy was not followed, resulting in incomplete care plans for the affected residents. The facility reported a census of 35 residents, and the deficiencies were identified through observations, interviews, and record reviews.
Failure to Issue Bed Hold Notice
Penalty
Summary
The facility failed to issue a bed hold notice to a resident or the resident’s representative during three separate hospitalizations. The resident was hospitalized on three occasions, and the facility was unable to provide documentation that a notice of the bed hold policy was given for any of these hospital stays. An email exchange with the Licensed Home Administrator confirmed that the facility did not have the required documentation to support that the bed hold policy was communicated on the specified dates. The facility's undated Notice of Bed-Hold policy indicated that the policy should be discussed with the resident or their representative upon admission, but there was no evidence this was done for the hospitalizations in question.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Clarksville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rehabilitation Center Of Allison | 6.7 mi | — | 0 | 0 |
| Shell Rock Senior Living | 7 mi | — | 0 | 0 |
| Woodland Terrace | 9.9 mi | — | 0 | 0 |
| Ams Memorial-greene | 10.1 mi | — | 0 | 0 |
| Maple Manor Village | 17.2 mi | — | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.