Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Spring Meadows Health and Rehabilitation
CLARKSVILLE, TN · 121 certified beds · Last Life Safety survey July 11, 2024
CMS Certification Number 445402 · first certified October 1997
Ownership
Operated by LYON HEALTHCARE · For profit - Limited Liability company
- New ownershipOwnership changed November 1, 2024 (change of ownership)to SPRING MEADOWS HEALTH & REHABILITATION from BEDROCKHC AT SPRING MEADOWS LLC
Position within TN
19 citations — more than 88% of the 303 certified nursing homes in TN. Compared within TN rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 13 citations; the earlier surveys in the window averaged 3. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: October 2025 to March 2028. This facility’s last Life Safety survey was July 2024. Facilities in TN are typically surveyed 15–44 months after the last one (median 33), measured over 279 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
4 of the 19 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 19 Life Safety citations above. The Physical Environment Index
- F-0584 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.
- F-0880 Provide and implement an infection prevention and control program.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
How that compares
Compared with the median facility in TN, and nationally. Surveyors differ markedly between states, so the TN figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 19 |
| Median facility in TN | 8 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| March 12, 2020 | 0 |
| July 25, 2022 | 6 |
| July 11, 2024 | 13 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 2 | 2024-07-11 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2024-07-11 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2024-07-11 |
| K-0222 | 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. | 2 | 2024-07-11 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2024-07-11 |
| E-0009 | Include a process for Emergency Preparedness collaboration. | 1 | 2024-07-11 |
| E-0037 | Establish staff and initial training requirements. | 1 | 2024-07-11 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2024-07-11 |
What the citations cover
- Smoke Deficiencies 6
- Egress Deficiencies 4
- Emergency Preparedness Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 6 |
| Egress Deficiencies | 4 |
| Emergency Preparedness Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Miscellaneous Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
July 11, 2024 — 13 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (July 10, 2024) |
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (July 30, 2024) |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (July 30, 2024) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (July 30, 2024) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (July 10, 2024) |
| K-0222 | 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. | Deficient, Provider has date of correction (July 31, 2024) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (August 22, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (July 10, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (July 22, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 19, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (July 26, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (August 1, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (July 31, 2024) |
July 25, 2022 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (July 28, 2022) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (July 18, 2022) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (July 18, 2022) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (July 19, 2022) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (July 18, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 27, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.