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)
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
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
Chain footprint
25 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 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
0.38
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.70
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.79
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.09
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.50
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
3.26
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,810
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.17
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 21.93% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Performance 9.19% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
5.47
Baseline 55.81% · Performance 41.30% · Measure score 5.47 · Achievement 5.47 · Improvement 4.19
Adjusted total nurse staffing
0.59
Baseline 3.68 hours · Performance 3.25 hours · Measure score 0.59 · Achievement 0.59 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.62% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 62 · Observed rate 11.29% · Lower 95% interval 6.46% |
| Discharge to community | 43.21% |
50.57%
7.4 pts worse
|
No Different than the National Rate · Eligible stays 52 · Observed rate 34.62% · Lower 95% interval 28.07% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 32 · Denominator 32 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 32 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 11 · Denominator 22 |
| Discharge mobility score | 45.45% |
50.94%
5.5 pts worse
|
Numerator 10 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 32 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 9.19% |
7.12%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 44 · Observed rate 15.91% · Lower 95% interval 5.65% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 98.86% |
42%
56.9 pts better
|
Numerator 87 · Denominator 88 |
| Discharge function score | 54.55% |
56.45%
1.9 pts worse
|
Numerator 12 · Denominator 22 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
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 · Adjusted 0.9 · Observed 0.9 · Expected 1.9 · Used in QM five-star |
| 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 · Adjusted 1.1 · Observed 1.2 · Expected 1.8 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 · 4Q avg 100.0% |
| 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 · Q1 8.5% · Q2 8.6% · Q3 7.5% · Q4 1.9% · 4Q avg 6.7% · Used in QM five-star |
| 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 · Q1 2.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% |
| 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 · Q1 4.3% · Q2 4.5% · Q3 0.0% · Q4 7.9% · 4Q avg 4.1% |
| 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 · Q1 27.7% · Q2 21.7% · Q3 26.8% · Q4 26.8% · 4Q avg 25.7% |
| 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 · Q1 16.7% · Q2 12.1% · Q3 6.1% · Q4 10.7% · 4Q avg 11.5% · Used in QM five-star |
| 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 · 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 | 13.2% |
15.4%
2.2 pts better
|
16.3%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.3% · Q2 5.0% · Q3 12.3% · 4Q avg 13.2% · Used in QM five-star |
| 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 · Q1 8.5% · Q2 10.9% · Q3 7.3% · Q4 27.5% · 4Q avg 13.2% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 6.0% · 4Q avg 1.4% · Used in QM five-star |
| 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 · Q1 8.4% · Q2 9.2% · Q3 5.3% · Q4 16.3% · 4Q avg 9.6% |
| 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 · Q1 9.2% · Q2 12.6% · Q3 10.0% · Q4 8.0% · 4Q avg 10.0% · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 76.5% · 4Q avg 93.8% |
| 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 · Q2 0.0% · 4Q avg 1.4% · Used in QM five-star |
| 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 · 4Q avg 100.0% |
Survey summary
Recent inspection cycles
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
Brown, Ruth
Operational/Managerial Control · Individual
Castle, Lisa
Operational/Managerial Control · Individual
Chambers County Public Hospital District No. 1
Operational/Managerial Control · Organization
Conley, Shawn
Operational/Managerial Control · Individual
Cooper, Kimberly
Operational/Managerial Control · Individual
Cooper, Kimberly
Corporate Officer · Individual
Focused Post Acute Care Partners LLC
Operational/Managerial Control · Organization
Focused Post Acute Care Partners Management, LLC
Operational/Managerial Control · Organization
Fpacp Clarksville LLC
Operational/Managerial Control · Organization
Mckenzie, Mark
Operational/Managerial Control · Individual
Muthappa, Deepak
Operational/Managerial Control · Individual
Newton, Elizabeth
Operational/Managerial Control · Individual
Strubbe, Loretta
Operational/Managerial Control · Individual
Weiselogel, Melisa
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Clarksville Nursing Home
Clarksville, TX
4-star overall rating with 3-star inspections with 13 recent health deficiencies
#2
Hill Nursing Home, Inc.
Idabel, OK
1-star overall rating with 1-star inspections with $116,810 in total fines with 6 recent health deficiencies
#3
Heritage House At Paris Rehab & Nursing
Paris, TX
3-star overall rating with 3-star inspections with 13 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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