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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.