Cycle 1
Health 2025-07-30 · Fire 2025-07-30
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
17 fire-safety deficiencies
Top issue: Emergency Preparedness (10 deficiencies)
Winchester, TN
Elk River Health & Nursing Center Of Winchester
3-star overall rating with 4-star inspections with 3 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
32 Memorial Drive, Winchester, TN
(931) 967-0200
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
55
Average occupied residents
Ownership
Non-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
0.54
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.24
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.94
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.79
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.38
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
3.71
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,659
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.59
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.98
Baseline 21.18% · Performance 20.98% · Measure score 0.98 · Achievement 0.98 · Improvement 0
Healthcare-associated infections
0
Baseline 9.27% · Performance 9.12% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.32
Baseline 51.47% · Performance 46.03% · Measure score 4.32 · Achievement 4.32 · Improvement 1.54
Adjusted total nurse staffing
2.54
Baseline 3 hours · Performance 3.80 hours · Measure score 2.54 · Achievement 2.54 · Improvement 2.38
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.38% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 106 · Observed rate 6.6% · Lower 95% interval 6.33% |
| Discharge to community | 48.6% |
50.57%
2 pts worse
|
No Different than the National Rate · Eligible stays 94 · Observed rate 43.62% · Lower 95% interval 37.3% |
| Medicare spending per beneficiary | 1.29 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 73 · Denominator 73 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 73 |
| Discharge self-care score | 44.68% |
53.69%
9 pts worse
|
Numerator 21 · Denominator 47 |
| Discharge mobility score | 38.3% |
50.94%
12.6 pts worse
|
Numerator 18 · Denominator 47 |
| Pressure ulcers or injuries, new or worsened | 6.85% |
2.29%
4.6 pts worse
|
Numerator 5 · Denominator 73 · Adjusted rate 5.42% |
| Healthcare-associated infections requiring hospitalization | 9.12% |
7.12%
2 pts worse
|
No Different than the National Rate · Eligible stays 77 · Observed rate 11.69% · Lower 95% interval 5.37% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 86 |
| Staff flu vaccination coverage | 40.74% |
42%
1.3 pts worse
|
Numerator 33 · Denominator 81 |
| Discharge function score | 42.55% |
56.45%
13.9 pts worse
|
Numerator 20 · Denominator 47 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 29 · Denominator 29 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 25 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 10% |
25.2%
15.2 pts worse
|
Numerator 4 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.1 |
1.6
1.5 pts worse
|
1.9
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 3.3 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.2 |
1.6
2.6 pts worse
|
1.8
2.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.2 · Observed 4.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.4% |
89.9%
6.5 pts better
|
93.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.6% · Q3 93.2% · Q4 95.2% · 4Q avg 96.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.7% |
94.5%
1.2 pts better
|
95.5%
0.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.0% |
3.6%
2.4 pts worse
|
3.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 9.8% · Q3 6.8% · Q4 2.4% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.5% |
11.8%
8.3 pts better
|
11.4%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 8.6% · Q3 2.4% · Q4 0.0% · 4Q avg 3.5% |
| Percentage of long-stay residents who lose too much weight | 10.9% |
6.2%
4.7 pts worse
|
5.4%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 5.9% · Q3 12.8% · Q4 17.9% · 4Q avg 10.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 37.3% |
32.2%
5.1 pts worse
|
19.6%
17.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 40.5% · Q3 33.3% · Q4 35.9% · 4Q avg 37.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.4% |
18.1%
5.7 pts better
|
16.7%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 3.3% · Q3 15.6% · Q4 16.7% · 4Q avg 12.4% · 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 need for help with daily activities has increased | 30.2% |
15.3%
14.9 pts worse
|
14.9%
15.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 46.4% · Q2 18.8% · Q3 30.3% · Q4 27.3% · 4Q avg 30.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.9%
0.4 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.9%
0.7 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.3% · Q4 2.4% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.7% |
20.2%
2.5 pts worse
|
19.8%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.8% · Q2 13.2% · Q3 18.2% · Q4 25.6% · 4Q avg 22.7% |
| Percentage of long-stay residents with pressure ulcers | 8.5% |
5.4%
3.1 pts worse
|
5.1%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 13.3% · Q3 8.4% · Q4 4.7% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.2% |
79.6%
10.6 pts better
|
81.7%
8.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.4% · Q2 91.4% · Q3 92.1% · Q4 87.8% · 4Q avg 90.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.0% |
11.2%
7.8 pts worse
|
12.0%
7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.0% · Observed 20.0% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.6%
1.6 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.4% |
79.8%
7.6 pts better
|
79.7%
7.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.5% |
22.2%
2.3 pts worse
|
23.9%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.5% · Observed 26.2% · Expected 25.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-03 · Fire 2024-04-03
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2021-12-14 · Fire 2021-12-14
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-07-30
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-09-13
D · Potential for more than minimal harm
2025-07-30
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2025-09-13
D · Potential for more than minimal harm
2025-07-30
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-09-13
D · Potential for more than minimal harm
2025-07-30
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2025-09-13
D · Potential for more than minimal harm
2025-07-30
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2025-09-13
D · Potential for more than minimal harm
2025-07-30
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-09-13
D · Potential for more than minimal harm
2025-07-30
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-09-13
D · Potential for more than minimal harm
2025-07-30
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-09-13
D · Potential for more than minimal harm
2025-07-30
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-09-13
D · Potential for more than minimal harm
2025-07-30
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-09-13
D · Potential for more than minimal harm
2025-07-30
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-09-13
D · Potential for more than minimal harm
2025-07-30
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 2025-09-13
D · Potential for more than minimal harm
2025-07-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-09-13
D · Potential for more than minimal harm
2025-07-30
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-09-13
D · Potential for more than minimal harm
2025-07-30
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-09-13
D · Potential for more than minimal harm
2025-07-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-13
D · Potential for more than minimal harm
2025-07-30
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-09-13
D · Potential for more than minimal harm
2024-04-03
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-04-03
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-04-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-04-03
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-04-26
D · Potential for more than minimal harm
2021-12-14
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2022-01-05
D · Potential for more than minimal harm
2021-12-14
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2022-01-05
D · Potential for more than minimal harm
2021-12-14
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2022-01-05
D · Potential for more than minimal harm
2021-12-14
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2022-01-05
D · Potential for more than minimal harm
2021-12-14
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-01-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-30
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-30
D · Potential for more than minimal harm
2025-07-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-30
D · Potential for more than minimal harm
2025-07-30
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 2025-08-30
F · Potential for more than minimal harm
2024-04-03
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 2024-05-03
D · Potential for more than minimal harm
2024-04-03
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-04-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-04-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-04-03
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-05-03
D · Potential for more than minimal harm
2021-12-14
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-01-05
Penalties and ownership
What sits behind the stars
Ownership
Ocoee Foundation Inc
5% Or Greater Direct Ownership Interest · Organization
Bradley, Don
Operational/Managerial Control · Individual
Burton, William
Operational/Managerial Control · Individual
Davis, Clinton
Operational/Managerial Control · Individual
Holcombe, Michelle
Operational/Managerial Control · Individual
Kupchynsky, Kathleen
Operational/Managerial Control · Individual
Malin, Douglas
Operational/Managerial Control · Individual
Ocoee Foundation Inc
Operational/Managerial Control · Organization
Phillips, Dorothy
Operational/Managerial Control · Individual
Pioneer Consulting LLC
Operational/Managerial Control · Organization
Sheehan, John
Operational/Managerial Control · Individual
Sheehan, John
Corporate Officer · Individual
Sheehan, Margaret
Operational/Managerial Control · Individual
Sheehan, Margaret
Corporate Officer · Individual
Smith, Frank
Operational/Managerial Control · Individual
Twin Rivers Health & Rehabilitation LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Southern Tenn Medical Center SNF
Winchester, TN
3-star overall rating with 2-star inspections with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
The Waters Of Winchester, LLC
Winchester, TN
4-star overall rating with 5-star inspections with $19,325 in total fines with 1 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
#3
Signature Healthcare Of Monteagle Rehab & Wellness
Monteagle, TN
2-star overall rating with 2-star inspections with $39,507 in total fines with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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