Ardmore, TN

Elk River Health And Nursing Center Of Ardmore, Ll

4-star overall rating with 4-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

24623 Union Hill Road, Ardmore, TN

(931) 427-2143

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

79

Certified beds

Average residents

56

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Twin Rivers Health & Rehabilitation

Operator or chain grouping

Approved since

1993-10-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

11 facilities

Chain averages 4 overall / 4 health / 3 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

0.37

Registered nurse staffing · state 0.61 · national 0.68

LPN hours / resident day

1.31

Licensed practical nurse staffing · state 1.09 · national 0.87

Aide hours / resident day

2.17

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

3.85

All reported nurse hours · state 3.85 · national 3.89

Licensed hours

1.68

RN + LPN hours · state 1.70 · national 1.54

Weekend hours

3.40

Weekend nurse staffing · state 3.34 · national 3.43

Weekend RN hours

0.30

Weekend registered nurse coverage · state 0.40 · national 0.47

Physical therapist

0.02

Reported PT staffing · state 0.08 · national 0.07

Adjusted RN hours

0.36

CMS adjusted RN staffing hours

Adjusted total hours

3.71

CMS adjusted total nurse staffing hours

Case-mix index

1.42

Higher values indicate more complex resident acuity

RN turnover

73%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

63%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,465

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

23.59

Composite VBP score used to determine payment impact.

Payment multiplier

0.9832

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 18.22% · Performance 22.44% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

5.50

Baseline 5.97% · Performance 6.19% · Measure score 5.50 · Achievement 5.50 · Improvement 0

Total nurse turnover

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Adjusted total nurse staffing

1.57

Baseline 2.71 hours · Performance 3.35 hours · Measure score 1.57 · Achievement 0.96 · Improvement 1.57

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.27%	10.72% 0.5 pts better	No Different than the National Rate · Eligible stays 121 · Observed rate 8.26% · Lower 95% interval 6.76%
Discharge to community	50.4%	50.57% 0.2 pts worse	No Different than the National Rate · Eligible stays 107 · Observed rate 48.6% · Lower 95% interval 41.85%
Medicare spending per beneficiary	1.4	1.02 0.4 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 58 · Denominator 58
Falls with major injury	1.72%	0.77% 0.9 pts worse	Numerator 1 · Denominator 58
Discharge self-care score	57.45%	53.69% 3.8 pts better	Numerator 27 · Denominator 47
Discharge mobility score	53.19%	50.94% 2.2 pts better	Numerator 25 · Denominator 47
Pressure ulcers or injuries, new or worsened	3.45%	2.29% 1.2 pts worse	Numerator 2 · Denominator 58 · Adjusted rate 3.42%
Healthcare-associated infections requiring hospitalization	6.19%	7.12% 0.9 pts better	No Different than the National Rate · Eligible stays 68 · Observed rate 2.94% · Lower 95% interval 3.51%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 60
Staff flu vaccination coverage	31.82%	42% 10.2 pts worse	Numerator 21 · Denominator 66
Discharge function score	63.83%	56.45% 7.4 pts better	Numerator 30 · Denominator 47
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Transfer of health information to patient	96.3%	96.28% About the same	Numerator 26 · Denominator 27
Resident COVID-19 vaccinations up to date	12.12%	25.2% 13.1 pts worse	Numerator 4 · Denominator 33

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.4	1.6 0.2 pts better	1.9 0.5 pts better	Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · Expected 1.5 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.2	1.6 0.4 pts better	1.8 0.6 pts better	Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	96.9%	89.9% 7 pts better	93.4% 3.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 93.0% · Q2 100.0% · Q3 98.1% · Q4 96.0% · 4Q avg 96.9%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	91.8%	94.5% 2.7 pts worse	95.5% 3.7 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 91.8%
Percentage of long-stay residents experiencing one or more falls with major injury	3.7%	3.6% 0.1 pts worse	3.3% 0.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.2% · Q3 3.8% · Q4 6.0% · 4Q avg 3.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	3.9%	11.8% 7.9 pts better	11.4% 7.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.1% · Q4 10.2% · 4Q avg 3.9%
Percentage of long-stay residents who lose too much weight	10.3%	6.2% 4.1 pts worse	5.4% 4.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 15.0% · Q3 9.5% · Q4 8.1% · 4Q avg 10.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	23.9%	32.2% 8.3 pts better	19.6% 4.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 24.4% · Q3 23.8% · Q4 25.6% · 4Q avg 23.9%
Percentage of long-stay residents who received an antipsychotic medication	17.9%	18.1% 0.2 pts better	16.7% 1.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 20.0% · Q3 15.2% · Q4 21.2% · 4Q avg 17.9% · 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	12.5%	19.9% 7.4 pts better	16.3% 3.8 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 12.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	10.9%	15.3% 4.4 pts better	14.9% 4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 11.4% · Q3 2.8% · Q4 5.7% · 4Q avg 10.9% · 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	1.6%	1.9% 0.3 pts better	1.7% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	20.1%	20.2% 0.1 pts better	19.8% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 23.9% · Q3 26.4% · Q4 8.1% · 4Q avg 20.1%
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 0.0% · Q2 3.9% · Q3 1.7% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	90.8%	79.6% 11.2 pts better	81.7% 9.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 94.3% · Q2 90.0% · Q3 90.2% · Q4 88.9% · 4Q avg 90.8%
Percentage of short-stay residents who had an outpatient emergency department visit	16.3%	11.2% 5.1 pts worse	12.0% 4.3 pts worse	Short Stay · 20240701-20250630 · Adjusted 16.3% · Observed 15.2% · Expected 10.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.9%	1.6% 1.3 pts worse	1.6% 1.3 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.3% · Q4 7.3% · 4Q avg 2.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	85.4%	79.8% 5.6 pts better	79.7% 5.7 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 85.4%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	22.9%	22.2% 0.7 pts worse	23.9% 1 pts better	Short Stay · 20240701-20250630 · Adjusted 22.9% · Observed 19.7% · Expected 20.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2020-01-23 · Fire 2020-01-23

2 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

4 fire-safety deficiencies

Top issue: Emergency Preparedness (2 deficiencies)

Cycle 2 Health 2019-02-27 · Fire 2019-02-27

4 health deficiencies

Top issue: Infection Control (1 deficiency)

6 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2018-04-17 · Fire 2018-04-17

5 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)

12 fire-safety deficiencies

Top issue: Emergency Preparedness (6 deficiencies)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2020-01-23

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2020-02-27

D · Potential for more than minimal harm 2020-01-23

E26 · Emergency Preparedness Deficiencies

Fire Safety

Establish roles under a Waiver declared by secretary.

Corrected 2020-02-27

D · Potential for more than minimal harm 2020-01-23

K232 · Egress Deficiencies

Fire Safety

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Corrected 2020-02-27

D · Potential for more than minimal harm 2020-01-23

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2020-02-27

D · Potential for more than minimal harm 2019-02-27

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2019-03-31

D · Potential for more than minimal harm 2019-02-27

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2019-03-31

D · Potential for more than minimal harm 2019-02-27

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2019-03-31

D · Potential for more than minimal harm 2019-02-27

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-03-31

D · Potential for more than minimal harm 2019-02-27

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2019-03-31

D · Potential for more than minimal harm 2019-02-27

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2019-03-31

D · Potential for more than minimal harm 2018-04-17

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2018-05-11

D · Potential for more than minimal harm 2018-04-17

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2018-05-11

D · Potential for more than minimal harm 2018-04-17

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2018-05-11

D · Potential for more than minimal harm 2018-04-17

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2018-05-11

D · Potential for more than minimal harm 2018-04-17

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 2018-05-11

D · Potential for more than minimal harm 2018-04-17

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2018-05-11

C · Minimal harm 2018-04-17

E24 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for volunteers.

Corrected 2018-05-11

C · Minimal harm 2018-04-17

E30 · Emergency Preparedness Deficiencies

Fire Safety

List the names and contact information of those in the facility.

Corrected 2018-05-11

C · Minimal harm 2018-04-17

E32 · Emergency Preparedness Deficiencies

Fire Safety

Provide primary/alternate means for communication.

Corrected 2018-05-11

C · Minimal harm 2018-04-17

E36 · Emergency Preparedness Deficiencies

Fire Safety

Establish emergency prep training and testing.

Corrected 2018-05-11

C · Minimal harm 2018-04-17

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2018-05-11

C · Minimal harm 2018-04-17

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2018-05-11

Inspection history

Recent health citations

D · Potential for more than minimal harm 2023-08-31

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2023-09-30

F · Potential for more than minimal harm 2020-01-23

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 2020-02-27

E · Potential for more than minimal harm 2020-01-23

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2020-02-27

D · Potential for more than minimal harm 2019-02-27

F622 · Resident Rights Deficiencies

Health

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Corrected 2019-03-12

D · Potential for more than minimal harm 2019-02-27

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 2019-03-07

D · Potential for more than minimal harm 2019-02-27

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 2019-03-12

D · Potential for more than minimal harm 2019-02-27

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-03-12

F · Potential for more than minimal harm 2018-04-17

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 2018-05-11

D · Potential for more than minimal harm 2018-04-17

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 2018-05-11

D · Potential for more than minimal harm 2018-04-17

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 2018-05-11

D · Potential for more than minimal harm 2018-04-17

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2018-05-11

Penalties and ownership

What sits behind the stars

Ownership

Ocoee Foundation Inc

5% Or Greater Direct Ownership Interest · Organization

100% 9 facilities 2019-04-01

Bradley, Don