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
Staffing
Hours and turnover
RN hours / resident day
0.54
Registered nurse staffing
LPN hours / resident day
1.24
Licensed practical nurse staffing
Aide hours / resident day
2.15
Nurse aide staffing
Weekend hours
3.38
Weekend nurse staffing
RN turnover
57%
Annual RN turnover
Total nurse turnover
53%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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