Inspection Reports for Tennessee State Veterans‘ Home – Clarksville
TN, 37042
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
2.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% better than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 21, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of sexual abuse involving two residents at the facility.
Complaint Details
The complaint involved allegations of sexual abuse between Resident #1 and Resident #2. The investigation included review of facility policies, medical records, camera footage, police reports, and multiple staff interviews. Resident #1 was found in Resident #2's room engaging in inappropriate sexual contact. Both residents were placed under 1:1 observation and separated. The police investigation was closed as the victim did not wish to continue prosecution.
Findings
The facility failed to ensure residents' right to be free from sexual abuse for two sampled residents. The investigation included policy review, medical records, camera footage, police report, and staff interviews, revealing inappropriate sexual interactions between residents and inadequate supervision.
Deficiencies (1)
Failure to protect residents from sexual abuse, including inadequate supervision and failure to prevent inappropriate interactions between residents.
Report Facts
BIMS score: 99
BIMS score: 12
Duration left unattended: 11
Date of incident: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Certified Nursing Assistant | Witnessed the inappropriate interaction between residents and provided a statement. |
| LPN C | Licensed Practical Nurse | Responded to the incident, instructed Resident #1 to leave the room, and reported the event. |
| Social Services Director | Social Services Director | Interviewed regarding Resident #2's cognitive status and behaviors. |
| Detective N | Police Detective | Conducted investigation and documented the case, which was later closed. |
| Officer M | Police Officer | Responded to the forcible sodomy allegation and made initial contact with Resident #2. |
| Former DON | Director of Nursing | Notified of the incident and provided information about Resident #1's behavior history. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 8, 2022
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to follow fall prevention interventions and infection control practices, resulting in resident injuries and potential COVID-19 exposure risks.
Complaint Details
The complaint investigation revealed substantiated findings that the facility failed to follow fall prevention protocols for Residents #22 and #25, resulting in serious injuries. It also found failure to follow CDC COVID-19 screening guidelines for staff, risking resident exposure.
Findings
The facility failed to follow fall prevention protocols for two residents, resulting in actual harm including multiple fractures and injuries. Additionally, the facility failed to implement proper infection prevention and control screening for COVID-19 among staff, potentially exposing residents to infection.
Deficiencies (3)
Failure to follow fall interventions resulting in actual harm to Resident #22 who sustained multiple fractures and injuries after a fall during a transfer with a Hoyer lift used by a single CNA instead of two staff.
Failure to follow fall interventions resulting in actual harm to Resident #25 who sustained a fracture of the greater trochanter after a fall when transferred without the required two-person assist.
Failure to provide and implement an infection prevention and control program, including failure of 9 employees to complete COVID-19 screenings prior to working on multiple days, potentially affecting 83 residents.
Report Facts
Residents affected: 2
Employees failed to screen: 9
Residents potentially affected by COVID-19 screening failure: 83
Fall Risk Assessment score: 14
Fall Risk Assessment score: 8
Fall Risk Assessment score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #7 | Certified Nursing Assistant | Involved in Resident #22's fall; transferred resident alone with Hoyer lift |
| RN #5 | Registered Nurse | Witnessed and reported on Resident #22's fall |
| Director of Rehabilitation | Director of Rehabilitation | Confirmed transfer requirements and resident dependency for Resident #22 and #25 |
| Director of Nursing | Director of Nursing | Confirmed Resident #22 was a two-person transfer and CNA #7 transferred alone |
| Administrator | Administrator | Confirmed policy violations regarding Resident #22's transfer |
| CNA #6 | Certified Nursing Assistant | Involved in Resident #25's fall; transferred resident alone |
| LPN #3 | Licensed Practical Nurse | Showed CNA #6 where Care Plans were after Resident #25's fall |
| Director of Clinical Services | Director of Clinical Services | Confirmed failure of multiple staff to complete COVID-19 screenings |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jun 12, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, accurate resident assessments, and medication administration practices at the Brigadier General Wendell H Gilbert TN State Veterans facility.
Findings
The facility was found to have failed in maintaining resident dignity during insulin administration, accurately assessing residents for contractures and medication use, and ensuring medication administration free of significant errors, including improper timing of insulin administration relative to food intake.
Deficiencies (3)
Failed to maintain resident dignity for 1 of 2 residents observed during insulin administration by exposing the resident's abdomen in the dining room with other residents present.
Failed to accurately assess residents for contractures and medications for 3 of 24 sampled residents, including incorrect coding on Minimum Data Set (MDS) assessments.
Failed to ensure medication administration free of significant errors; specifically, a nurse administered insulin to Resident #18 without timely food intake, resulting in a significant medication error.
Report Facts
Units of insulin administered: 4
Time delay in food intake after insulin administration: 86
Number of residents sampled for assessment accuracy: 24
Number of residents with inaccurate assessments: 3
Number of residents observed during insulin administration: 2
Number of residents affected by dignity deficiency: 1
Number of residents affected by medication error: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in medication error finding and dignity deficiency during insulin administration. |
| Director of Nursing | Director of Nursing | Interviewed regarding insulin administration practices and confirmed deficiencies. |
| MDS Coordinator #1 | MDS Coordinator | Interviewed regarding inaccurate MDS coding for residents. |
| MDS Coordinator #2 | MDS Coordinator | Interviewed regarding missed contracture assessment. |
| Regional Nurse Consultant | Regional Nurse Consultant | Interviewed regarding accuracy of MDS assessments. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 9, 2018
Visit Reason
The inspection was conducted following a complaint investigation regarding a burn injury to Resident #35 caused by improper use of a HotPac (moist heat therapy device) by a Certified Nursing Assistant (CNA) without a physician's order.
Complaint Details
The complaint investigation was substantiated as the facility failed to prevent a CNA from applying a HotPac outside her scope of practice without a physician order, resulting in actual harm to Resident #35. The investigation included interviews with staff and review of medical records, physician orders, incident reports, and facility policies.
Findings
The facility failed to implement an effective policy for the application and use of HotPacs, resulting in Resident #35 suffering a deep partial thickness burn from an unmonitored HotPac. The CNA applied the HotPac outside her scope of practice without physician orders or adequate supervision. The facility also lacked temperature monitoring of the Hydrocollator unit prior to the incident and had no nursing policy for HotPac application.
Deficiencies (3)
Failure to prevent a CNA from applying a HotPac without a physician order, resulting in a deep partial thickness burn to Resident #35.
Lack of policy for nursing personnel to apply HotPacs to residents prior to the burn incident.
Failure to monitor Hydrocollator temperature prior to the burn incident.
Report Facts
Incident report date: Jul 10, 2018
Hydrocollator inspection date: Sep 14, 2017
Hydrocollator water temperature: 158
HotPac surface temperature: 145
Burn area size: 7.5
Burn area size: 5
Blister size: 4.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Applied HotPac to Resident #35 without physician order or nurse supervision |
| LPN #1 | Licensed Practical Nurse | Resident #35's nurse on the day of the burn incident, unaware of HotPac application |
| Rehabilitation Manager | Provided information on HotPac usage and confirmed lack of written policy | |
| Director of Clinical Services | Confirmed no nursing policy existed for HotPac application | |
| DON | Director of Nursing | Unaware of nursing staff applying HotPacs prior to incident and confirmed unsafe practice |
| Administrator | Acknowledged responsibility for ensuring staff practice within scope and was aware of the incident | |
| CNA #2 | Certified Nursing Assistant | Discovered the burn on Resident #35 and described circumstances |
| CNA #3 | Certified Nursing Assistant | Worked on Resident #35's unit and reported lack of communication about HotPac |
| Resident #35's physician | Physician | Confirmed no physician orders were given for nursing to apply HotPacs |
| LPN #2 | Licensed Practical Nurse | Confirmed dialysis communication form was not completed for Resident #59 |
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