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

Compare this facility

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

Staffing

Hours and turnover

RN hours / resident day

0.36

Registered nurse staffing

LPN hours / resident day

1.22

Licensed practical nurse staffing

Aide hours / resident day

2.02

Nurse aide staffing

Weekend hours

3.21

Weekend nurse staffing

RN turnover

20%

Annual RN turnover

Total nurse turnover

35%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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 ability to walk independently worsened	19.8%	19.9% 0.1 pts better	16.3% 3.5 pts worse	Long Stay · 2024Q4-2025Q3
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
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
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
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
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
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
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
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
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
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

Survey summary

Recent inspection cycles

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)

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