Cycle 1
Health 2024-11-25 · Fire 2024-11-25
3 health deficiencies
Top issue: Administration (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Woodbury, TN
Woodbury Health And Rehabilitation Center
2-star overall rating with 2-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
119 West High Street, Woodbury, TN
(615) 563-5939
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
82
Certified beds
Average residents
76
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Twin Rivers Health & Rehabilitation
Operator or chain grouping
Approved since
2002-01-01
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
0.36
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.22
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.02
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.61
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.21
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.33
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
0.35
CMS adjusted RN staffing hours
Adjusted total hours
3.49
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,761
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.70
Composite VBP score used to determine payment impact.
Payment multiplier
0.9917
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.55
Baseline 19.13% · Performance 18.86% · Measure score 5.55 · Achievement 5.55 · Improvement 0.76
Healthcare-associated infections
1.95
Baseline 6.83% · Performance 7.25% · Measure score 1.95 · Achievement 1.95 · Improvement 0
Total nurse turnover
6.45
Baseline 40.32% · Performance 37.33% · Measure score 6.45 · Achievement 6.45 · Improvement 1.43
Adjusted total nurse staffing
1.54
Baseline 2.94 hours · Performance 3.52 hours · Measure score 1.54 · Achievement 1.54 · Improvement 1.53
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.01% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 125 · Observed rate 5.6% · Lower 95% interval 6.41% |
| Discharge to community | 47.14% |
50.57%
3.4 pts worse
|
No Different than the National Rate · Eligible stays 112 · Observed rate 41.07% · Lower 95% interval 39.05% |
| Medicare spending per beneficiary | 1.23 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 98.68% |
95.27%
3.4 pts better
|
Numerator 75 · Denominator 76 |
| Falls with major injury | 2.63% |
0.77%
1.9 pts worse
|
Numerator 2 · Denominator 76 |
| Discharge self-care score | 79.63% |
53.69%
25.9 pts better
|
Numerator 43 · Denominator 54 |
| Discharge mobility score | 48.15% |
50.94%
2.8 pts worse
|
Numerator 26 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 2.63% |
2.29%
0.3 pts worse
|
Numerator 2 · Denominator 76 · Adjusted rate 2.21% |
| Healthcare-associated infections requiring hospitalization | 7.25% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 75 · Observed rate 6.67% · Lower 95% interval 4.21% |
| Staff COVID-19 vaccination coverage | 0.99% |
8.2%
7.2 pts worse
|
Numerator 1 · Denominator 101 |
| Staff flu vaccination coverage | 21.65% |
42%
20.4 pts worse
|
Numerator 21 · Denominator 97 |
| Discharge function score | 61.11% |
56.45%
4.7 pts better
|
Numerator 33 · Denominator 54 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 22 · Denominator 22 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 33 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 17.78% |
25.2%
7.4 pts worse
|
Numerator 8 · Denominator 45 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.6
0.1 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.6
0.5 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
89.9%
9.4 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 100.0% · Q3 100.0% · Q4 98.5% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.5%
5.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.6% |
3.6%
3 pts worse
|
3.3%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 7.4% · Q3 5.6% · Q4 4.6% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.3% |
11.8%
0.5 pts worse
|
11.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 14.3% · Q3 10.4% · Q4 13.1% · 4Q avg 12.3% |
| Percentage of long-stay residents who lose too much weight | 4.3% |
6.2%
1.9 pts better
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 10.9% · Q3 4.5% · Q4 0.0% · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.1% |
32.2%
0.1 pts better
|
19.6%
12.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 35.3% · Q3 29.4% · Q4 33.3% · 4Q avg 32.1% |
| 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 11.1% · Q2 19.0% · Q3 20.7% · Q4 20.4% · 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 | 19.8% |
19.9%
0.1 pts better
|
16.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 41.0% · Q3 0.0% · 4Q avg 19.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.2% |
15.3%
6.1 pts better
|
14.9%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 9.7% · Q3 6.6% · Q4 8.9% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.9%
0.6 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
1.9%
1.5 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 4.7% · Q3 1.4% · Q4 3.4% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.4% |
20.2%
3.2 pts worse
|
19.8%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 24.4% · Q3 23.6% · Q4 22.2% · 4Q avg 23.4% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
5.4%
3.2 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.7% · Q3 2.4% · Q4 1.2% · 4Q avg 2.2% · 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 | 14.4% |
11.2%
3.2 pts worse
|
12.0%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.4% · Observed 13.3% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 6.9% |
1.6%
5.3 pts worse
|
1.6%
5.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 8.3% · Q3 12.9% · Q4 2.6% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
79.8%
20.2 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.5% |
22.2%
5.3 pts worse
|
23.9%
3.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.5% · Observed 26.7% · Expected 23.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-02-16 · Fire 2022-02-16
10 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-05-15 · Fire 2019-05-15
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-11-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-23
D · Potential for more than minimal harm
2019-05-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-05-28
D · Potential for more than minimal harm
2019-05-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-05-28
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-11-25
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 2025-01-08
F · Potential for more than minimal harm
2024-11-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-08
D · Potential for more than minimal harm
2024-11-25
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-01-08
J · Immediate jeopardy
2022-02-16
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2022-03-09
D · Potential for more than minimal harm
2022-02-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-05-03
D · Potential for more than minimal harm
2022-02-16
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 2022-03-10
D · Potential for more than minimal harm
2022-02-16
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 2022-03-10
D · Potential for more than minimal harm
2022-02-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-03-09
D · Potential for more than minimal harm
2022-02-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-03-09
D · Potential for more than minimal harm
2022-02-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-03-09
D · Potential for more than minimal harm
2022-02-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-03-09
D · Potential for more than minimal harm
2022-02-16
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-03-09
D · Potential for more than minimal harm
2022-02-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-09
F · Potential for more than minimal harm
2019-05-15
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 2019-06-21
Penalties and ownership
What sits behind the stars
Ownership
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
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, Margaret
Operational/Managerial Control · Individual
Smith, Frank
Operational/Managerial Control · Individual
Spurlock, James
Operational/Managerial Control · Individual
Twin Rivers Health & Rehabilitation LLC
Operational/Managerial Control · Organization
Ward, Michael
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Nhc Healthcare, Smithville
Smithville, TN
3-star overall rating with 2-star inspections with $228,511 in total fines with 2 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
#2
Nhc Healthcare, Murfreesboro
Murfreesboro, TN
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Stone River Post Acute
Murfreesboro, TN
3-star overall rating with 3-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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