Fayetteville, TN

Elk River Health & Rehabilitation Of Fayetteville

4-star overall rating with 4-star inspections with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle

4081 Thornton Taylor Parkway, Fayetteville, TN

(931) 433-9973

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

79

Certified beds

Average residents

51

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

0.43

Registered nurse staffing · state 0.61 · national 0.68

LPN hours / resident day

1.04

Licensed practical nurse staffing · state 1.09 · national 0.87

Aide hours / resident day

2.41

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

3.87

All reported nurse hours · state 3.85 · national 3.89

Licensed hours

1.46

RN + LPN hours · state 1.70 · national 1.54

Weekend hours

3.60

Weekend nurse staffing · state 3.34 · national 3.43

Weekend RN hours

0.41

Weekend registered nurse coverage · state 0.40 · national 0.47

Physical therapist

0.05

Reported PT staffing · state 0.08 · national 0.07

Adjusted RN hours

0.44

CMS adjusted RN staffing hours

Adjusted total hours

4.01

CMS adjusted total nurse staffing hours

Case-mix index

1.32

Higher values indicate more complex resident acuity

RN turnover

67%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

59%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,602

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

Performance score

11.53

Composite VBP score used to determine payment impact.

Payment multiplier

0.9810

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 21.53% · Performance 22.62% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

0

Baseline 6.62% · Performance 8.89% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

2.65

Baseline 55.81% · Performance 52.83% · Measure score 2.65 · Achievement 2.65 · Improvement 0.46

Adjusted total nurse staffing

1.96

Baseline 2.60 hours · Performance 3.38 hours · Measure score 1.96 · Achievement 1.08 · Improvement 1.96

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.81%	10.72% 1.1 pts worse	No Different than the National Rate · Eligible stays 79 · Observed rate 13.92% · Lower 95% interval 8.76%
Discharge to community	42.88%	50.57% 7.7 pts worse	No Different than the National Rate · Eligible stays 60 · Observed rate 35% · Lower 95% interval 31.45%
Medicare spending per beneficiary	1.57	1.02 0.6 pts worse
Drug regimen review with follow-up	90.57%	95.27% 4.7 pts worse	Numerator 48 · Denominator 53
Falls with major injury	1.89%	0.77% 1.1 pts worse	Numerator 1 · Denominator 53
Discharge self-care score	64.44%	53.69% 10.8 pts better	Numerator 29 · Denominator 45
Discharge mobility score	48.89%	50.94% 2 pts worse	Numerator 22 · Denominator 45
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 53 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	8.89%	7.12% 1.8 pts worse	No Different than the National Rate · Eligible stays 56 · Observed rate 12.5% · Lower 95% interval 5.41%
Staff COVID-19 vaccination coverage	4.69%	8.2% 3.5 pts worse	Numerator 3 · Denominator 64
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge function score	64.44%	56.45% 8 pts better	Numerator 29 · Denominator 45
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Transfer of health information to patient	80.77%	96.28% 15.5 pts worse	Numerator 21 · Denominator 26
Resident COVID-19 vaccinations up to date	0%	25.2% 25.2 pts worse	Numerator 0 · Denominator 35

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.0	1.6 0.6 pts better	1.9 0.9 pts better	Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.1	1.6 0.5 pts worse	1.8 0.3 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.1 · Expected 1.7 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	89.9% 10.1 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	85.7%	94.5% 8.8 pts worse	95.5% 9.8 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 85.7%
Percentage of long-stay residents experiencing one or more falls with major injury	9.9%	3.6% 6.3 pts worse	3.3% 6.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 8.7% · Q3 12.2% · Q4 10.3% · 4Q avg 9.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.6%	11.8% 11.2 pts better	11.4% 10.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.7% · 4Q avg 0.6%
Percentage of long-stay residents who lose too much weight	0.7%	6.2% 5.5 pts better	5.4% 4.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.3% · 4Q avg 0.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	23.4%	32.2% 8.8 pts better	19.6% 3.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 22.0% · Q3 27.3% · Q4 16.7% · 4Q avg 23.4%
Percentage of long-stay residents who received an antipsychotic medication	17.7%	18.1% 0.4 pts better	16.7% 1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 27.3% · Q3 17.4% · Q4 7.7% · 4Q avg 17.7% · 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	34.6%	19.9% 14.7 pts worse	16.3% 18.3 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 34.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	22.7%	15.3% 7.4 pts worse	14.9% 7.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 48.8% · Q2 25.6% · Q3 6.5% · Q4 0.0% · 4Q avg 22.7% · 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	0.0%	1.9% 1.9 pts better	1.7% 1.7 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 new or worsened bowel or bladder incontinence	19.1%	20.2% 1.1 pts better	19.8% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 33.9% · Q2 22.1% · Q3 13.6% · Q4 4.6% · 4Q avg 19.1%
Percentage of long-stay residents with pressure ulcers	6.3%	5.4% 0.9 pts worse	5.1% 1.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.1% · Q3 8.8% · Q4 13.1% · 4Q avg 6.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	79.6% 20.4 pts better	81.7% 18.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of short-stay residents who had an outpatient emergency department visit	15.1%	11.2% 3.9 pts worse	12.0% 3.1 pts worse	Short Stay · 20240701-20250630 · Adjusted 15.1% · Observed 15.1% · Expected 11.2% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	4.0%	1.6% 2.4 pts worse	1.6% 2.4 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 1.9% · Q3 3.4% · Q4 4.0% · 4Q avg 4.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	89.0%	79.8% 9.2 pts better	79.7% 9.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 89.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	23.6%	22.2% 1.4 pts worse	23.9% 0.3 pts better	Short Stay · 20240701-20250630 · Adjusted 23.6% · Observed 19.2% · Expected 19.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-10 · Fire 2025-09-10

2 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

7 fire-safety deficiencies

Top issue: Emergency Preparedness (4 deficiencies)

Cycle 2 Health 2024-07-11 · Fire 2024-07-11

2 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

6 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 3 Health 2022-04-20 · Fire 2022-04-20

4 health deficiencies

Top issue: Infection Control (1 deficiency)

1 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-09-10

K222 · Egress Deficiencies

Fire Safety

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.

Corrected 2025-10-15

D · Potential for more than minimal harm 2025-09-10

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2025-10-15

D · Potential for more than minimal harm 2025-09-10

E32 · Emergency Preparedness Deficiencies

Fire Safety

Provide primary/alternate means for communication.

Corrected 2025-10-15

D · Potential for more than minimal harm 2025-09-10

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2025-10-15

D · Potential for more than minimal harm 2025-09-10

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2025-10-15

D · Potential for more than minimal harm 2025-09-10

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-10-15

D · Potential for more than minimal harm 2025-09-10

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 2025-10-15

D · Potential for more than minimal harm 2024-07-11

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 2024-08-20

D · Potential for more than minimal harm 2024-07-11

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-08-20

D · Potential for more than minimal harm 2024-07-11

K521 · Services Deficiencies

Fire Safety

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

Corrected 2024-08-20

D · Potential for more than minimal harm 2024-07-11

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 2024-08-20

D · Potential for more than minimal harm 2024-07-11

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-08-20

D · Potential for more than minimal harm 2024-07-11

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-08-20

D · Potential for more than minimal harm 2022-04-20

K222 · Egress Deficiencies

Fire Safety

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.

Corrected 2022-05-13

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-09-10

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-10-15

D · Potential for more than minimal harm 2025-09-10

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 2025-09-19

F · Potential for more than minimal harm 2024-07-11

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 2024-08-20

D · Potential for more than minimal harm 2024-07-11

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 2024-08-20

F · Potential for more than minimal harm 2022-04-20

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 2022-05-13

D · Potential for more than minimal harm 2022-04-20

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2022-05-13

D · Potential for more than minimal harm 2022-04-20

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 2022-05-13

D · Potential for more than minimal harm 2022-04-20

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-05-13

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