Focused Care At Clarksville
FOCUSED CARE AT CLARKSVILLE in CLARKSVILLE, TX — inspection on February 25, 2026.
Found 6 citations. 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 02/25/2026 at 10:45 a.m., the DON said the MDS Nurse was responsible for all MDS in the facility with the Clinical Reimbursement was the backup that double checked random MDSs.
She said the MDS Nurse was educated on the completion of MDSs.
The DON said the MDSs marked incorrectly were overlooked.
She said she expected all MDSs in the facility to be correct and accurate.
The DON said the resident risk of an MDS marked incorrectly was the MDS may not paint a good picture of residents and the care the residents needed.
During an interview on 02/25/2026 at 11:00 a.m., the Administrator said the MDS Nurse was responsible for all MDSs in the facility and was educated on the completion of MDSs.
She said the Clinical Reimbursement was the backup to double check some MDSs for accuracy.
The Administrator said the resident risk of an MDS not marked correctly was the MDS may not paint a good picture of the resident and resident's care.
She said her expectation was all MDSs be correct and accurate.
Record review of the facility's policy titled, Resident Assessment, revised 11/15/2023, indicated, .
The purpose of this policy is to ensure accuracy and timeliness of MDS completion. 1.
Each facility must follow most updated MDS RAI rules and regulations for completing each MDS accurately and timely.
Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, indicated .A1500: Preadmission Screening and Resident Review (PASRR).
Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. .J1300: Current Tobacco Use coding .
Steps for Assessment 1.
Ask the resident if they used tobacco in any form during the 7-day look-back period. 2. If the resident states that they used tobacco in some form during the 7-day look-back period, code 1.
Yes.
Coding Instructions, Code, no: if there are no indications that the resident used any form of tobacco.
Code 1, yes: if the resident or any other source indicates that the resident used tobacco in some form during the look-back period Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, indicated .Guidelines for Determining When a Significant Change Should Result in Referral for a Preadmission Screening and Resident Review (PASRR) Level II Evaluation: If an SCSA occurs for an individual known or suspected to have a mental illness, intellectual disability, or related condition (as defined by 42 CFR 483.102), a referral to the State Mental Health or Intellectual Disability/Developmental Disabilities Administration authority (SMH/ID/DDA) for a possible Level II PASRR evaluation must promptly occur as required by Section 1919(e)(7)(B)(iii) of the Social Security Act.5
455944 02/25/2026
Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426
all-inclusive.
455944 02/25/2026
Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426
During an attempted interview on 02/25/2026 at 12:15 p.m., the Pharmacy Technician message was left to return call with no response.
Record review of the Monthly Consultant Pharmacist Report, dated 02/13/2026, indicated, .Medication Cart for Halls 100, 200, 300 was reviewed expired medication was removed with no medication labeling or dating concerns .
Record review of a facility policy, revised 08/2020, titled, Preventing and Detecting Adverse Consequences and Medication Errors, indicated, . d.
Checking the medication storage areas and the medication carts for proper storage and labeling of medications, cleanliness, and removal of expired medications. 7. No expired medication will be administered to a resident. 8.
All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining. In order to safeguard the quality and stability of medications used within the facility, medications brought to the facility by other than the designated pharmacist or agent can be accepted only if there is a current order for use, the medication is in a proper container properly labeled, the medication has not expired, and the medication has been positively identified by the physician or pharmacist prior to use.
The facility will have documentation that the identification has been made.
Review of the Policy and Procedures - Pharmacy Services for Nursing Facilities, dated 08/2020, indicated the following.Policy: Medications classified by the Drug Enforcement Administration (DEA) as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations.
Procedures: 5.
Unless otherwise indicated in a facility policy and/or as required by state regulations, the following will be performed: a) at each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed personnel and is documented.
455944 02/25/2026
Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426
Findings included:1.
Record review of a face sheet dated 02/25/26 indicated Resident #5 was a [AGE] year-old male readmitted on [DATE].
His diagnoses included malignant neoplasm (uncontrolled growth of cells) of the prostate (a gland in the male reproductive system) and paraplegia (injury to the spinal cord or brain that stops signals from reaching the lower body).
Record review of February 2026 physician orders for Resident #5 indicated he had an order dated 12/26/25 to receive Methenamine Hippurate Oral Tablet 1 GM 1 tablet by mouth two times a day for urinary antiseptics.
There was no stop date on the order.
Record review of a Physician Progress Notes dated 01/29/26 for Resident #5 indicated there was no documentation as for the reason for no stop date on the order. 2.
Record review of a face sheet dated 02/25/26 indicated Resident #32 was a [AGE] year-old female readmitted on [DATE].
Her diagnoses included kidney failure (condition where the kidney reaches advanced state of loss of function).
Record review of February 2026 physician orders for Resident #32 indicated she had an order dated 01/28/2026 to receive Bactrim DS Oral Tablet 800-160 mg (Sulfamethoxazole-Trimethoprim) 1 tablet by mouth one time a day for chronic UTIs.
There was no stop date on the order.
Record review of a Physician Progress Note dated 01/29/26 for Resident #32 indicated there was no documentation as for the reason for no stop date on the order.
During an interview on 02/25/2026 at 09:05 a.m. IP indicated she thought the physician had ordered the antibiotic prophylactically (to prevent infection) for UTI.
She indicated she did not see any notes from the physician about the antibiotic.
She indicated she would reach out to request any documentation they may have.
During an interview on 02/25/2026 at 10:20 a.m. the DON indicated she understood there should be documentation to support why an antibiotic would be given for an extended length of time as well as follow up/reviews of the residents.
During an Interview on 02/25/2026 at 11:00 a.m., the Administrator indicated she expected staff and physicians to follow protocols regarding antibiotic orders.
Record review of an Antibiotic Stewardship Program Policy revised 10/01/22 indicated POLICY:The Community has a formal Antibiotic Stewardship Program (ASP) to optimize the treatment of infections, reduce the risk of adverse events, including the development of antibiotic-resistant organisms and employs Community-wide system to monitor the appropriate use of antibiotics.ANTIBIOTIC STEWARDSHIP PROGRAM (ASP) CORE ELEMENTS: 1.
Leadership Commitment to demonstrate support and commitment to safe and appropriate antibiotic use in the community.7.
Resources and education are provided to clinicians, nursing staff, residents and families about antibiotic resistance and opportunities for improving antibiotic use. b.
Licensed independent practitioners (LIPs) are provided written education, the Community Antibiotic Stewardship Program and appropriate prescribing protocols upon credentialing and as needed. At the discretion of the Administrator or Community Medical Director, LIPs may be reeducated or provided with additional educational materials to improve antibiotic prescribing practices.ANTIBIOTIC STEWARDSHIP TEAM:The Community has an Antibiotic Stewardship Team to implement and direct the Core Elements of the ASP.
The Team includes but is not limited to the following: .2.
Medical Director or another licensed independent practitioner: a.
Provides or assists in the provision of prescribing practices for credentialed clinical providers b.
Oversees adherence to antibiotic prescribing practices for credentialed providers and offers written feedback regarding prescribing practices and compliance with antibiotic use protocols, which may include: .iii.
Prescription documentation: indication for use, dosage, duration. iv.
Clinical justification for use of an antibiotic beyond initial duration ordered.
455944 02/25/2026
Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426
interview on 02/25/2026 at 10:20 a.m. the DON indicated staff should place gloves in a plastic bag to
hand hygiene between glove changes.
She said they could spread infections to the residents or to
staff to follow the policies on hand hygiene and glove use.
Record review of a Hand Hygiene policy revised 10/24/22 indicated Policy:.1.
You should always perform hand hygiene:.Before applying and after removing personal protective equipment (e.g. gloves, gown, mask, face shield/goggles), Before and after providing any type of care.2.
You must perform hand hygiene (hand washing or the use of ABHR) after contact with bodily fluids, such as urine or blood, mucous membranes, such as the mouth or nose, and non-intact skin.
455944 02/25/2026
Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426
Findings included:During an observation and interview on 02/23/2026 at 08:53 a.m. the stove's two right burners were not lighting when the knobs turned on.
Observation indicated the pilot lights to the two burners were not lit.
The DM said they had to be lit with a long lighter.
The DM said the stove should light without using a lighter. He said having to light the stove with a lighter could cause an explosion possibly causing injuries to residents.
Observation indicated there was no hissing sound of gas and no foul smell of gas coming from the burners.
During an interview on 02/24/26 at 11:05 a.m. the DM said the MD had looked at the stove after surveyor saw it and it still had a problem but there was no gas coming out unless the knobs were turned on. He said someone was supposed to be coming today to repair it.
During an Interview on 02/25/26 at 11:00 a.m., the Administrator said she expected kitchen equipment to be working correctly.
She said due to the stove being gas it could cause a fire and possible injuries.
During an interview and record review on 02/25/26 at 11:30 a.m. the DM said someone had come and repaired the stove. He showed surveyor an equipment repair receipt for the stove.
Record review of a Preventative Maintenance and Repair of Equipment policy dated 04/2022 indicated POLICY:The facility Plant Operations personnel will perform monthly inspections of kitchen equipment to ensure proper care of equipment and reduce cost by providing preventative maintenance in a timely manner.
Record review of the FDA Food Code 2022 accessed on 02/25/26 at https://www.fda.gov/food/retail-food-protection/fda-food-code 4-5 Maintenance and Operation4-501 Equipment4-501.11 Good Repair and Proper Adjustment.(A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.