Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% better than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 6
May 28, 2025
Visit Reason
The inspection was conducted based on complaints and allegations regarding failure to provide dignified care, failure to notify residents/families of trust fund balances, failure to report abuse and injuries of unknown origin, failure to ensure a safe environment free of accident hazards, failure to follow physician's orders for oxygen therapy, and failure to implement infection control practices during medication administration.
Findings
The facility was found deficient in multiple areas including failure to provide hair care to a resident, failure to notify families about resident trust fund balances exceeding limits, failure to report alleged abuse and injuries of unknown origin, failure to ensure adequate supervision and fall prevention leading to multiple falls including serious injuries, failure to follow physician's orders for oxygen therapy, and failure to follow infection control protocols during medication administration.
Complaint Details
The complaint investigation included allegations of failure to provide dignified care, failure to notify residents/families of trust fund balances exceeding limits, failure to report abuse and injuries of unknown origin, failure to ensure a safe environment free of accident hazards, failure to follow physician's orders for oxygen therapy, and failure to implement infection control practices during medication administration. The facility was found noncompliant in all these areas with Immediate Jeopardy identified related to fall prevention and supervision.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to provide care and services to promote dignity for Resident #36 when they failed to provide hair care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to notify family and/or resident when the amount in the residents' account exceeded the eligibility limit for Resident #2 and #31. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation for Residents #28 and #82. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure a safe and secure environment and provide adequate supervision to prevent accidents for Residents #31, #50, #248, #498, and #501, resulting in Immediate Jeopardy for Resident #498. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to follow Physician's Orders for oxygen therapy for Resident #14. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure infection control practices were followed during medication administration for Residents #8 and #22. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 5
Residents affected: 2
Residents affected: 2
Fall count: 14
Fall risk score: 21
Oxygen liters per minute: 2
Oxygen liters per minute observed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Used stethoscope without cleaning and failed to rinse syringe during medication administration for Resident #22 |
| LPN B | Licensed Practical Nurse | Failed to cleanse wrist cuff after use during medication administration for Resident #8 |
| Director of Nursing | Director of Nursing (DON) | Confirmed failures in neuro checks, fall investigations, and infection control practices |
| Certified Nursing Assistant K | Certified Nursing Assistant | Reported bruising on Resident #28 and completed witness statement |
| Social Worker | Social Worker | Witnessed family member hit Resident #82 and intervened |
| Administrator | Administrator | Did not report injury of unknown origin to state agency and confirmed failures in fall reporting |
Inspection Report
Routine
Deficiencies: 5
May 26, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to baseline care plans, comprehensive care plans, physician orders, catheter care, and PICC line management for sampled residents.
Findings
The facility failed to provide accurate baseline and comprehensive care plans for 4 sampled residents, did not follow physician orders for 3 residents, lacked physician orders and assessments for urinary catheters for 2 residents, and failed to follow professional standards for PICC line care and medication administration for 3 residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide an accurate Baseline Care Plan for 4 of 4 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide an accurate and revised Comprehensive Care Plan for 4 of 4 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow physician's orders for 3 of 4 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to have a physician's order for urinary catheter use, assessment for removal, or demonstrate necessity for 2 of 2 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow professional standards for PICC line infusion therapy, medication administration, and obtain physician orders for 3 of 3 sampled residents with PICC lines. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 4
Physician orders dates: 2023
Medication doses missed: 1
PICC flush intervals: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding accuracy of baseline and comprehensive care plans, catheter orders, and PICC line care |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed regarding delayed speech therapy evaluation for Resident #1 |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding lack of awareness of 1:1 supervision order for Resident #2 during meals |
Inspection Report
Complaint Investigation
Deficiencies: 3
Sep 6, 2019
Visit Reason
The inspection was conducted due to concerns about medication error rates exceeding 5 percent, specifically reviewing medication administration practices by nursing staff.
Findings
The facility failed to ensure that two nurses administered medications with an error rate below 5 percent, with 2 errors observed out of 27 opportunities, resulting in a 7.4% error rate. Specific medication errors included administering double the prescribed dose of acetaminophen to one resident and failing to administer docusate sodium to another resident as ordered.
Complaint Details
The visit was complaint-related due to medication error concerns. The errors were substantiated based on observations and interviews with nursing staff and the Director of Nursing.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Medication error rate exceeded 5 percent with 2 errors observed out of 27 opportunities. | Level of Harm - Minimal harm or potential for actual harm |
| RN administered 2 tablets of acetaminophen 500 mg instead of 1 as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| LPN failed to administer docusate sodium as ordered. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 7.4074074074
Medication errors observed: 2
Medication administration opportunities: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Administered incorrect dose of acetaminophen resulting in medication error. |
| LPN #1 | Licensed Practical Nurse | Failed to administer docusate sodium as ordered, resulting in medication error. |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration expectations. |
Inspection Report
Deficiencies: 0
Oct 9, 2018
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Signature Healthcare of Clarksville, summarizing the findings from a survey completed on 2018-10-09.
Findings
No health deficiencies were found during the survey.
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