Cycle 1
Health 2024-07-11 · Fire 2024-07-11
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Clarksville, TN
Spring Meadows Health and Rehabilitation
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
220 Highway 76, Clarksville, TN
(931) 552-0219
Overall
2 / 5
CMS overall stars
Health inspections
1 / 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
121
Certified beds
Average residents
112
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lyon Healthcare
Operator or chain grouping
Approved since
1997-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 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
0.41
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.02
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.38
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.20
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
3.16
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,914
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.62
Composite VBP score used to determine payment impact.
Payment multiplier
0.9885
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.02% · Performance 22.00% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
7.07
Baseline 7.23% · Performance 5.72% · Measure score 7.07 · Achievement 7.07 · Improvement 6.25
Total nurse turnover
5.25
Baseline 55.29% · Performance 42.20% · Measure score 5.25 · Achievement 5.25 · Improvement 3.80
Adjusted total nurse staffing
1.52
Baseline 2.64 hours · Performance 3.27 hours · Measure score 1.52 · Achievement 0.68 · Improvement 1.52
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.17% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 142 · Observed rate 10.56% · Lower 95% interval 8.59% |
| Discharge to community | 46.72% |
50.57%
3.9 pts worse
|
No Different than the National Rate · Eligible stays 109 · Observed rate 44.04% · Lower 95% interval 39.45% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 96.55% |
95.27%
1.3 pts better
|
Numerator 84 · Denominator 87 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 87 |
| Discharge self-care score | 56.14% |
53.69%
2.5 pts better
|
Numerator 32 · Denominator 57 |
| Discharge mobility score | 45.61% |
50.94%
5.3 pts worse
|
Numerator 26 · Denominator 57 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 87 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.72% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 71 · Observed rate 1.41% · Lower 95% interval 3.19% |
| Staff COVID-19 vaccination coverage | 1.32% |
8.2%
6.9 pts worse
|
Numerator 2 · Denominator 152 |
| Staff flu vaccination coverage | 24.2% |
42%
17.8 pts worse
|
Numerator 53 · Denominator 219 |
| Discharge function score | 57.89% |
56.45%
1.4 pts better
|
Numerator 33 · Denominator 57 |
| Transfer of health information to provider | 96% |
95.95%
About the same
|
Numerator 24 · Denominator 25 |
| Transfer of health information to patient | 93.02% |
96.28%
3.3 pts worse
|
Numerator 40 · Denominator 43 |
| Resident COVID-19 vaccinations up to date | 38.46% |
25.2%
13.3 pts better
|
Numerator 20 · Denominator 52 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.6
0.8 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.6
0.5 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
89.9%
9.6 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.9% · Q3 100.0% · Q4 98.9% · 4Q avg 99.5% |
| 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 | 1.6% |
3.6%
2 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.2% · Q3 2.3% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.0% |
11.8%
5.8 pts better
|
11.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.7% · Q3 8.4% · Q4 10.2% · 4Q avg 6.0% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
6.2%
0.9 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 5.4% · Q3 8.2% · Q4 2.5% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.0% |
32.2%
11.2 pts better
|
19.6%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 20.8% · Q3 20.5% · Q4 20.3% · 4Q avg 21.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.4% |
18.1%
0.7 pts better
|
16.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 19.7% · Q3 14.3% · Q4 16.7% · 4Q avg 17.4% · 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 | 22.1% |
19.9%
2.2 pts worse
|
16.3%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 38.3% · Q4 11.0% · 4Q avg 22.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.3% |
15.3%
3 pts better
|
14.9%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 17.1% · Q3 12.3% · Q4 8.5% · 4Q avg 12.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 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 | 0.3% |
1.9%
1.6 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.3% |
20.2%
7.1 pts worse
|
19.8%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.1% · Q2 27.9% · Q3 30.5% · Q4 19.7% · 4Q avg 27.3% |
| Percentage of long-stay residents with pressure ulcers | 1.4% |
5.4%
4 pts better
|
5.1%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.1% · Q3 1.0% · Q4 1.8% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.4% |
79.6%
3.8 pts better
|
81.7%
1.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.4% · Q2 91.1% · Q3 78.3% · Q4 77.9% · 4Q avg 83.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.8% |
11.2%
0.6 pts worse
|
12.0%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.8% · Observed 11.8% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.6%
1.6 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.1% |
79.8%
3.3 pts better
|
79.7%
3.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.6% |
22.2%
0.6 pts better
|
23.9%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.6% · Observed 21.2% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-07-25 · Fire 2022-07-25
9 health deficiencies
Top issue: Administration (2 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2020-03-12 · Fire 2020-03-12
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-07-11
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-07-30
D · Potential for more than minimal harm
2024-07-11
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-07-30
D · Potential for more than minimal harm
2024-07-11
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-07-11
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-07-30
D · Potential for more than minimal harm
2024-07-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-07-11
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-07-11
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-08-22
D · Potential for more than minimal harm
2024-07-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-07-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-22
D · Potential for more than minimal harm
2024-07-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-07-11
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-07-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-07-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-07-31
D · Potential for more than minimal harm
2022-07-25
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2022-07-28
D · Potential for more than minimal harm
2022-07-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-07-18
D · Potential for more than minimal harm
2022-07-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-07-18
D · Potential for more than minimal harm
2022-07-25
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-07-19
D · Potential for more than minimal harm
2022-07-25
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-07-18
D · Potential for more than minimal harm
2022-07-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-27
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-07-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-10
D · Potential for more than minimal harm
2024-07-11
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 2024-08-10
D · Potential for more than minimal harm
2024-07-11
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-08-10
D · Potential for more than minimal harm
2024-07-11
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-08-10
D · Potential for more than minimal harm
2024-07-11
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-08-10
D · Potential for more than minimal harm
2024-07-11
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-08-10
E · Potential for more than minimal harm
2023-05-05
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-07-14
J · Immediate jeopardy
2023-04-26
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 2023-04-26
J · Immediate jeopardy
2022-07-25
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-08-19
J · Immediate jeopardy
2022-07-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-08-19
J · Immediate jeopardy
2022-07-25
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 2022-08-19
J · Immediate jeopardy
2022-07-25
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2022-08-19
J · Immediate jeopardy
2022-07-25
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-08-19
F · Potential for more than minimal harm
2022-07-25
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 2022-08-19
F · Potential for more than minimal harm
2022-07-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-19
E · Potential for more than minimal harm
2022-07-25
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 2022-08-19
D · Potential for more than minimal harm
2022-07-25
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-08-19
F · Potential for more than minimal harm
2020-03-12
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 2020-04-26
E · Potential for more than minimal harm
2020-03-12
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2020-04-26
D · Potential for more than minimal harm
2020-03-12
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 2020-04-26
D · Potential for more than minimal harm
2020-03-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-04-26
D · Potential for more than minimal harm
2020-03-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-04-26
D · Potential for more than minimal harm
2020-03-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-04-26
Penalties and ownership
What sits behind the stars
$18,264
2023-04-26
Fine
Fine · fine $18,264
Fine
Ownership
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
Signature Healthcare Of Clarksville
Clarksville, TN
2-star overall rating with 2-star inspections with $63,105 in total fines with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
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
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