Clarksville, TX

Focused Care At Clarksville

3-star overall rating with 2-star inspections with abuse icon flag with $5,211 in total fines with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

2407 West Main Street, Clarksville, TX

(903) 427-3821

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

57

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Focused Post Acute Care Partners

Operator or chain grouping

Approved since

1991-09-12

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.38

Registered nurse staffing

LPN hours / resident day

0.71

Licensed practical nurse staffing

Aide hours / resident day

1.70

Nurse aide staffing

Weekend hours

2.50

Weekend nurse staffing

RN turnover

40%

Annual RN turnover

Total nurse turnover

43%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 0.9
2.1
1.2 pts better
1.9
1 pts better
Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days 1.1
2.1
1 pts better
1.8
0.7 pts better
Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 100.0%
97.1%
2.9 pts better
93.4%
6.6 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 100.0%
97.9%
2.1 pts better
95.5%
4.5 pts better
Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury 6.7%
3.3%
3.4 pts worse
3.3%
3.4 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms 0.5%
2.7%
2.2 pts better
11.4%
10.9 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight 4.1%
3.3%
0.8 pts worse
5.4%
1.3 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication 25.7%
18.9%
6.8 pts worse
19.6%
6.1 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication 11.5%
10.8%
0.7 pts worse
16.7%
5.2 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained 0.0%
0.0%
About the same
0.1%
0.1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened 13.2%
15.4%
2.2 pts better
16.3%
3.1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased 13.2%
16.1%
2.9 pts better
14.9%
1.7 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.0%
0.5%
0.5 pts better
1.0%
1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection 1.4%
0.8%
0.6 pts worse
1.7%
0.3 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 9.6%
15.0%
5.4 pts better
19.8%
10.2 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers 10.0%
4.2%
5.8 pts worse
5.1%
4.9 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 93.8%
89.7%
4.1 pts better
81.7%
12.1 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who newly received an antipsychotic medication 1.4%
1.5%
0.1 pts better
1.6%
0.2 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 100.0%
88.0%
12 pts better
79.7%
20.3 pts better
Short Stay · 2024Q3-2025Q2

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-12-04 · Fire 2024-12-04

6 health deficiencies

Top issue: Environmental (1 deficiency)

5 fire-safety deficiencies

Top issue: Services (2 deficiencies)

Cycle 2 Health 2023-11-02 · Fire 2023-11-02

20 health deficiencies

Top issue: Pharmacy Service (4 deficiencies)

1 fire-safety deficiencies

Top issue: Services (1 deficiency)

Cycle 3 Health 2022-08-31 · Fire 2022-08-31

5 health deficiencies

Top issue: Nutrition and Dietary (3 deficiencies)

1 fire-safety deficiencies

Top issue: Services (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-12-04

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-01-03

E · Potential for more than minimal harm 2024-12-04

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-01-03

E · Potential for more than minimal harm 2024-12-04

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-01-03

E · Potential for more than minimal harm 2024-12-04

K929 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

Corrected 2025-01-03

C · Minimal harm 2024-12-04

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

C · Minimal harm 2023-11-02

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

C · Minimal harm 2022-08-31

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-05-21

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2025-04-04

E · Potential for more than minimal harm 2024-12-04

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-12-20

D · Potential for more than minimal harm 2024-12-04

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 2024-12-20

D · Potential for more than minimal harm 2024-12-04

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2024-12-20

D · Potential for more than minimal harm 2024-12-04

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-12-20

D · Potential for more than minimal harm 2024-12-04

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2024-12-20

D · Potential for more than minimal harm 2024-11-21

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2024-08-08

G · Actual harm 2024-10-05

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 2024-10-30

F · Potential for more than minimal harm 2023-11-02

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-11-24

E · Potential for more than minimal harm 2023-11-02

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2023-11-24

E · Potential for more than minimal harm 2023-11-02

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 2023-11-24

E · Potential for more than minimal harm 2023-11-02

F758 · Pharmacy Service Deficiencies

Health

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.

Corrected 2023-11-24

E · Potential for more than minimal harm 2023-11-02

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2023-11-24

E · Potential for more than minimal harm 2023-11-02

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2023-11-24

E · Potential for more than minimal harm 2023-11-02

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2023-11-24

E · Potential for more than minimal harm 2023-11-02

F809 · Nutrition and Dietary Deficiencies

Health

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Corrected 2023-11-24

E · Potential for more than minimal harm 2023-11-02

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-11-27

E · Potential for more than minimal harm 2023-11-02

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2023-11-24

E · Potential for more than minimal harm 2023-11-02

F926 · Environmental Deficiencies

Health

Have policies on smoking.

Corrected 2023-11-24

D · Potential for more than minimal harm 2023-11-02

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 2023-11-24

D · Potential for more than minimal harm 2023-11-02

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2023-11-24

D · Potential for more than minimal harm 2023-11-02

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2023-11-24

D · Potential for more than minimal harm 2023-11-02

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-11-24

D · Potential for more than minimal harm 2023-11-02

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2023-11-24

D · Potential for more than minimal harm 2023-11-02

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2023-11-24

D · Potential for more than minimal harm 2023-11-02

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2023-11-24

F · Potential for more than minimal harm 2022-08-31

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2022-09-23

E · Potential for more than minimal harm 2022-08-31

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2022-09-23

E · Potential for more than minimal harm 2022-08-31

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2022-09-23

E · Potential for more than minimal harm 2022-08-31

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2022-09-23

E · Potential for more than minimal harm 2022-08-31

F813 · Nutrition and Dietary Deficiencies

Health

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Corrected 2022-09-23

Penalties and ownership

What sits behind the stars

$5,211 2024-10-05

Fine

Fine · fine $5,211

Fine

Ownership

Chambers County Public Hospital District No. 1

5% Or Greater Direct Ownership Interest · Organization

100% 19 facilities 2021-05-01
Brown, Ruth

Operational/Managerial Control · Individual

0% 1 facilities 2021-05-01
Castle, Lisa

Operational/Managerial Control · Individual

0% 1 facilities 2023-03-27
Chambers County Public Hospital District No. 1

Operational/Managerial Control · Organization

0% 19 facilities 2021-05-01
Conley, Shawn

Operational/Managerial Control · Individual

0% 25 facilities 2021-05-01
Cooper, Kimberly

Operational/Managerial Control · Individual

0% 13 facilities 2024-01-29
Cooper, Kimberly

Corporate Officer · Individual

0% 13 facilities 2024-01-29
Focused Post Acute Care Partners LLC

Operational/Managerial Control · Organization

0% 22 facilities 2021-05-01
Focused Post Acute Care Partners Management, LLC

Operational/Managerial Control · Organization

0% 25 facilities 2021-05-01
Fpacp Clarksville LLC

Operational/Managerial Control · Organization

0% 1 facilities 2021-05-01
Mckenzie, Mark

Operational/Managerial Control · Individual

0% 25 facilities 2021-05-01
Muthappa, Deepak

Operational/Managerial Control · Individual

0% 1 facilities 2021-05-01
Newton, Elizabeth

Operational/Managerial Control · Individual

0% 20 facilities 2024-02-22
Strubbe, Loretta

Operational/Managerial Control · Individual

0% 25 facilities 2021-05-01
Weiselogel, Melisa

Operational/Managerial Control · Individual

0% 1 facilities 2021-05-18

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