A list of the most recent deficiencies for Clarksville Health and Rehab Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-29 | 2024-01-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-29 | 2024-01-10 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-12-12 | 2023-03-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-12 | 2023-03-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-12 | 2023-03-27 | N |
| Use approved construction type or materials. | Fire Safety | 2022-12-12 | 2023-01-27 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-12-12 | 2023-01-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-12 | 2023-01-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-12 | 2023-01-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-12-12 | 2023-01-27 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-12-12 | 2023-01-27 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-12-12 | 2023-01-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-30 | 2023-01-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-30 | 2023-01-04 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-11-30 | 2023-01-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-11-30 | 2023-01-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-04-19 | 2021-07-19 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-04-19 | 2021-06-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-04-19 | 2021-06-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-04-19 | 2021-06-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-19 | 2021-06-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-04-19 | 2021-06-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-04-19 | 2021-06-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-19 | 2021-06-07 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-04-01 | 2021-05-12 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-04-01 | 2021-05-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-01 | 2021-05-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-01 | 2021-05-12 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-04-01 | 2021-05-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-04-01 | 2021-05-12 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-04-01 | 2021-05-12 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-04-01 | 2021-05-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-01 | 2021-05-12 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-04-01 | 2021-05-12 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-02-19 | 2019-04-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-02-19 | 2019-04-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-02-19 | 2019-04-08 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-02-19 | 2019-04-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-01-31 | 2019-03-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-31 | 2019-03-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-01-31 | 2019-03-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-01-31 | 2019-03-16 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2019-01-31 | 2019-03-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-01-31 | 2019-03-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-01-31 | 2019-03-16 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-01-31 | 2019-03-16 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-01-31 | 2019-03-16 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-01-31 | 2019-03-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-31 | 2019-03-16 | N |
