Brigadier General Wendell H Gilbert Tn State Veter
BRIGADIER GENERAL WENDELL H GILBERT TN STATE VETER in CLARKSVILLE, TN — inspection on November 21, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 10/22/2025 at 11:43 AM, CNA B stated she has been working at the facility for about 8 years and served as an activity staff. CNA B stated on 11/23/2023 she was preparing to leave after her shift and went to answer a call-light in Resident #2's room.
When she entered, she found Resident #1 naked lying on his stomach between the opened legs of Resident #2. Resident #2 was also unclothed from the waist down.
When asked whether there were any covers present on the bed, CNA B stated, they were off. Resident #2 stated she wanted the CNA to bring her something for pain because she had a headache.
When asked Resident #1's reaction to CNA B entering the room, she stated she did not think that Resident #1 knew that she was there. CNA B stated she then left the room, went down the hall to find the nurse and the nurse was the one that got Resident #1 off of Resident #2.
Once Resident #1 left the room, he returned to his private room. CNA B then stated she went to find the supervisor. CNA B went home after having given her employee statement. CNA B stated when Resident #1 returned to facility after psychiatric hospitalization, CNA B stated Resident #1 was transferred to another room in the 600 House (each section/hall was called a house - which consists of resident rooms, a kitchen area and a living room or common social area). CNA B was asked whether Resident #1 had ever displayed sexual aggression previously and she stated this was the first time she had seen him in anyone else's room.
During an interview on 10/22/2025 at 5:24 PM, the Social Services Director (SSD) was asked about Resident #2's cognitive ability at the time of the incident.
The SSD stated .even though [Resident #2] scored initially high I feel that [Resident #2] was confused.
During a phone interview on 10/23/2025 at 8:13 AM, LPN C was asked to explain the incident that happened on 11/23/2023 between Resident #1 and Resident #2. LPN C stated, It was towards the beginning of the shift I was on the other side of the common area passing meds.
The CNA [CNA B] went into the room [Resident #2's room] and came out yelling that she needed the nurse and I [LPN C] went into the room [Resident #2's room] and named Resident [Resident #2] was laying in her bed with no brief on, it was in the floor, and she had her gown pulled up below her breast.
Named Resident [Resident #1] was in bed with her between her legs.LPN C told Resident #1 he needed to get up and he said No, we are fine. LPN C said You have to leave and Resident #1 got up and got dressed and was walked out by a staff member. LPN C asked Resident #2 if she was ok and if she wanted him in there and she just said I didn't know what he wanted.
There was a CNA that stayed in the common area to ensure the residents stayed in their own rooms. LPN C stated the next time she came to work, there was a Velcro stop sign placed across the threshold of Resident #2's room .
During an interview on 10/23/2025 at 2:42 PM, the former DON (current Regional Consultant) stated she was notified of this incident and then notified the Administrator (The Abuse Coordinator).
The former DON stated Resident #2 exhibited accusatory behaviors, and staff would ensure they had a witness to ensure they were not accused falsely. Resident #2 had behaviors mostly related to self-removal of her colostomy bag.
The former DON was asked whether Resident #1 had ever had any episodes of sexual aggression, and she stated there had been no sexual behavior noted with Resident #1 prior to this incident and there had been no incident of sexual aggression afterwards.
Facility ID: