Cycle 1
Health 2022-04-08 · Fire 2022-04-08
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Clarksville, TN
Brigadier General Wendell H Gilbert Tn State Veter
3-star overall rating with 3-star inspections with 3 recent health deficiencies
250 Arrowood Drive, Clarksville, TN
(931) 245-4700
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
108
Certified beds
Average residents
105
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Tennessee State Veterans' Home
Operator or chain grouping
Approved since
2016-05-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 4 overall / 4 health / 4 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.53
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.64
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
3.26
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
5.44
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
2.17
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
4.72
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.58
CMS adjusted RN staffing hours
Adjusted total hours
5.97
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
3,187
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.56
Composite VBP score used to determine payment impact.
Payment multiplier
0.9988
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.94
Baseline 22.24% · Performance 20.45% · Measure score 2.94 · Achievement 2.12 · Improvement 2.94
Healthcare-associated infections
2.31
Baseline 8.97% · Performance 7.85% · Measure score 2.31 · Achievement 0 · Improvement 2.31
Total nurse turnover
2.97
Baseline 45.22% · Performance 51.53% · Measure score 2.97 · Achievement 2.97 · Improvement 0
Adjusted total nurse staffing
10
Baseline 5.11 hours · Performance 5.97 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.62% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 69 · Observed rate 13.04% · Lower 95% interval 7.47% |
| Discharge to community | 39.16% |
50.57%
11.4 pts worse
|
Worse than the National Rate · Eligible stays 55 · Observed rate 30.91% · Lower 95% interval 27.39% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 43 · Denominator 43 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 43 |
| Discharge self-care score | 32.26% |
53.69%
21.4 pts worse
|
Numerator 10 · Denominator 31 |
| Discharge mobility score | 32.26% |
50.94%
18.7 pts worse
|
Numerator 10 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 43 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.86% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 11.11% · Lower 95% interval 4.39% |
| Staff COVID-19 vaccination coverage | 1.19% |
8.2%
7 pts worse
|
Numerator 2 · Denominator 168 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 22.58% |
56.45%
33.9 pts worse
|
Numerator 7 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 16.67% |
25.2%
8.5 pts worse
|
Numerator 4 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.6
0.5 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.4 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.6
0.2 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
89.9%
9.8 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.5%
5.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.3% |
3.6%
2.7 pts worse
|
3.3%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 8.3% · Q3 6.1% · Q4 5.9% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
11.8%
11.2 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 6.7% |
6.2%
0.5 pts worse
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 12.0% · Q3 3.3% · Q4 1.1% · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.3% |
32.2%
12.9 pts better
|
19.6%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 17.4% · Q3 19.6% · Q4 13.8% · 4Q avg 19.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.1% |
18.1%
8 pts better
|
16.7%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 8.8% · Q3 8.8% · Q4 16.7% · 4Q avg 10.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 30.8% |
19.9%
10.9 pts worse
|
16.3%
14.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 29.7% · Q3 40.2% · Q4 25.2% · 4Q avg 30.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.0% |
15.3%
15.7 pts worse
|
14.9%
16.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 39.1% · Q3 42.2% · Q4 16.1% · 4Q avg 31.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
0.9%
1 pts worse
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.3% · Q3 2.2% · Q4 1.9% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.3% |
1.9%
2.4 pts worse
|
1.7%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 5.2% · Q3 3.1% · Q4 5.0% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.7% |
20.2%
4.5 pts worse
|
19.8%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.8% · Q2 22.5% · Q3 22.7% · Q4 21.0% · 4Q avg 24.7% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
5.4%
2.5 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 3.0% · Q3 1.9% · Q4 3.8% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
79.6%
17 pts better
|
81.7%
14.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.2% · Q2 100.0% · Q3 100.0% · Q4 93.5% · 4Q avg 96.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.0% |
11.2%
1.2 pts better
|
12.0%
2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.0% · Observed 10.9% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 6.3% |
1.6%
4.7 pts worse
|
1.6%
4.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.5% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.6% |
79.8%
17.8 pts better
|
79.7%
17.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.7% |
22.2%
6.5 pts better
|
23.9%
8.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.7% · Observed 16.4% · Expected 24.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-06-12 · Fire 2019-06-12
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2018-08-09 · Fire 2018-08-09
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-21
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-12-12
G · Actual harm
2022-04-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-05-03
F · Potential for more than minimal harm
2022-04-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-03
D · Potential for more than minimal harm
2019-06-12
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-07-27
D · Potential for more than minimal harm
2019-06-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-07-27
D · Potential for more than minimal harm
2019-06-12
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2019-07-27
G · Actual harm
2018-08-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2018-09-04
D · Potential for more than minimal harm
2018-08-09
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2018-09-04
Penalties and ownership
What sits behind the stars
Ownership
Brown, Danielle
W-2 Managing Employee · Individual
Harries, Edward
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Ahava Healthcare Of Clarksville
Clarksville, TN
2-star overall rating with 3-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Park Meadows Post Acute
Clarksville, TN
2-star overall rating with 2-star inspections with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Spring Meadows Health and Rehabilitation
Clarksville, TN
2-star overall rating with 1-star inspections with $18,264 in total fines with 6 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
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