Elk River Health & Nursing Center of Winchester
32 Memorial Drive, Winchester, TN 37398 · Franklin County · (931) 967-0200
80 certified beds, about 52 residents a day · Non profit - Other · Medicare and Medicaid since 1993
Certified for Medicaid Certified for Medicare
Overall
3 of 5
Health inspections
4 of 5
Staffing
1 of 5
Quality measures
2 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 445319 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on July 30, 2025, inspectors cited 3 health deficiencies (the Tennessee average is 4.4, the national average 9.2).
None of its 9 health citations since December 2021 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 3.70 hours per resident per day, against 3.80 across Tennessee and 3.86 nationally. Registered nurses accounted for 0.56 of those hours.
69.7% of nursing staff left within the year CMS measured (Tennessee average 48.9%).
CMS links it to Twin Rivers Health & Rehabilitation, an affiliated group of 11 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
112/21
504/24
307/25
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 9 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
8D
0E
1F
Potential for minimal harm
0A
0B
0C
July 30, 2025Standard inspection, Complaint inspection · 3 citations
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on facility policy review, medical record review, facility investigation documentation review, and interviews, staff failed to report an allegation of resident-to-resident abuse to administration for 1 resident (Resident #13) of 4 residents reviewed for abuse.
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on facility policy review, Resident Assessment Instrument (RAI) Manual 3.0 review, medical record review, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 resident (Resident #48) of 24 residents reviewed.
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to revise the comprehensive care plan for 1 resident (Resident #3) of 16 residents reviewed for care plans.
April 3, 2024Standard inspection · 5 citations
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on facility policy review, observation, and interview, the facility failed to ensure food items were sealed properly and the facility failed to ensure the kitchen was maintained in a good-working and sanitary order, which had the potential to affect 57 of 58 residents.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on facility policy review, medical record review, observations, and interviews, the facility failed to implement a comprehensive person-centered care plan related to falls for 1 resident (Resident #19) and adaptive eating utensils for 1 resident (Resident #46) of 15 residents reviewed for comprehensive care plans.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review, observations, and interviews the facility failed to follow a physician's order for 1 resident (Resident #19) related to fall interventions and adaptive eating utensils for 1 resident (Resident #46) of 15 residents reviewed for physician orders.
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to provide tracheostomy (a surgical procedure where a tube is inserted in the neck to allow air to enter the lungs) care (a procedure performed routinely to keep the part of the tracheostomy tube/faceplate that is fixed against the neck, tracheostomy dressing, ties or straps, and surrounding area clean) according to the facilities policy and physicians order for 1 resident (Resident #45) of 1 resident reviewed for tracheostomy care.
- D Dispose of garbage and refuse properly.
Inspectors wroteBased on facility policy review, observation, and interview, the facility failed to ensure garbage and refuse were properly contained in 2 of 2 dumpsters (dumpster A and B).
December 14, 2021Standard inspection · 1 citation
- D 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.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to properly label an enteral feeding for 1 resident (Resident #5) of 3 residents reviewed with an enteral feeding.
Fire safety inspections
26 fire safety citations on file: 17 on July 30, 2025, 4 on April 3, 2024, 5 on December 14, 2021.
Every fire safety citation26 citations
- D Develop and maintain an Emergency Preparedness Program (EP).
- D Conduct risk assessment and an All-Hazards approach.
- D Address subsistence needs for staff and patients.
- D Establish policies and procedures for volunteers.
- D Establish roles under a Waiver declared by secretary.
- D Provide primary/alternate means for communication.
- D Provide a means of sharing information on occupancy/needs.
- D Provide family notifications of emergency plan.
- D Establish staff and initial training requirements.
- D Conduct testing and exercise requirements.
- D Have corridors or aisles that are unobstructed and are at least 8 feet in width.
- D Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- D Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- D To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- D Have generator or other power source capable of supplying service within 10 seconds.
- D Ensure that testing and maintenance of electrical equipment is performed.
- D List the names and contact information of those in the facility.
- D Establish methods for sharing information.
- D Provide properly protected cooking facilities.
- D Install an approved automatic sprinkler system.
- D Develop and maintain an Emergency Preparedness Program (EP).
- D Establish policies and procedures including evacuation.
- D Establish roles under a Waiver declared by secretary.
- D Establish methods for sharing information.
- D Provide a means of sharing information on occupancy/needs.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Tennessee | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.70 | 3.80 | 3.86 |
| Registered nurses | 0.56 | 0.60 | 0.69 |
| All nursing staff on weekends | 3.24 | 3.31 | 3.42 |
| Nurse aides | 1.86 | ||
| Licensed practical nurses | 1.27 | ||
| Nursing staff turnover (share who left in a year) | 69.7% | 48.9% | 45.8% |
| Registered nurse turnover | 50.0% | 43.2% | 42.9% |
| Administrators who left | 1 |
CMS expects 4.34 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.89 on weekdays and 3.24 on weekends, 17% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 2.2% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.21 in April to June 2025 to 3.70 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.70 | 0.56 | 3.89 | 3.24 | 2.2% | 0 of 90 | 52 |
| Oct to Dec 2025 | 3.82 | 0.56 | 4.05 | 3.24 | 10.4% | 0 of 92 | 56 |
| Jul to Sep 2025 | 3.94 | 0.54 | 4.15 | 3.38 | 12.6% | 3 of 92 | 55 |
| Apr to Jun 2025 | 4.21 | 0.62 | 4.50 | 3.50 | 11.7% | 0 of 91 | 54 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Tennessee, Jan to Mar 2026 | 3.75 | 0.56 | 3.95 | 3.27 | 4.0% | 0.7% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Tennessee | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 17.9 | 14.0 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.7 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 4.0 | 1.8 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.8 | 3.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 2.1 | 1.7 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 17.1 | 17.2 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 5.5 | 5.0 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 11.3 | 16.9 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 32.5 | 22.6 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 15.9 | 11.2 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.4 | 1.7 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.7 | 1.6 | 1.8 |
Owners and operators
Legal business name: ELK RIVER HEALTH & NURSING CENTER OF WINCHESTER, LLC. CMS links this home to Twin Rivers Health & Rehabilitation, a group of 11 nursing homes averaging 3.9 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Bradley, Don | Managing control - governing body | Individual | 02/07/2024 | |
| Burton, William | Managing control - governing body | Individual | 02/07/2024 | |
| Kupchynsky, Kathleen | Managing control - governing body | Individual | 02/07/2024 | |
| Phillips, Dorothy | Managing control - governing body | Individual | 02/07/2024 | |
| Sheehan, John | Managing control - governing body | Individual | 02/07/2024 | |
| Sheehan, Margaret | Managing control - governing body | Individual | 12/15/2022 | |
| Smith, Frank | Managing control - governing body | Individual | 02/07/2024 | |
| Sheehan, John | Corporate officer | Individual | 02/07/2024 | |
| Sheehan, Margaret | Corporate officer | Individual | 12/15/2022 | |
| Ocoee Foundation Inc | Operational/managerial control | Organization | 04/01/2019 | |
| Pioneer Consulting LLC | Operational/managerial control | Organization | 04/01/2019 | |
| Twin Rivers Health & Rehabilitation LLC | Operational/managerial control | Organization | 04/01/2019 | |
| Bradley, Don | Operational/managerial control | Individual | 02/07/2024 | |
| Burton, William | Operational/managerial control | Individual | 02/07/2024 | |
| Davis, Clinton | Operational/managerial control | Individual | 04/01/2019 | |
| Holcombe, Michelle | Operational/managerial control | Individual | 04/01/2019 | |
| Kupchynsky, Kathleen | Operational/managerial control | Individual | 02/07/2024 | |
| Malin, Douglas | Operational/managerial control | Individual | 02/28/2024 | |
| Phillips, Dorothy | Operational/managerial control | Individual | 02/07/2024 | |
| Sheehan, John | Operational/managerial control | Individual | 02/07/2024 | |
| Sheehan, Margaret | Operational/managerial control | Individual | 04/01/2019 | |
| Smith, Frank | Operational/managerial control | Individual | 02/07/2024 | |
| Ocoee Foundation Inc | Adp of the SNF | Organization | 04/01/2019 | |
| Ocoee Winchester Property Investment LLC | Adp of the SNF | Organization | 04/01/2019 | |
| Pioneer Consulting LLC | Adp of the SNF | Organization | 04/14/2025 | |
| Twin Rivers Health & Rehabilitation LLC | Adp of the SNF | Organization | 04/14/2025 | |
| Davis, Clinton | Adp of the SNF | Individual | 04/01/2019 | |
| Gammada, Ephraim | Adp of the SNF | Individual | 02/28/2024 | |
| Holcombe, Michelle | Adp of the SNF | Individual | 04/01/2019 | |
| Malin, Douglas | Adp of the SNF | Individual | 02/28/2024 | |
| Sheehan, John | Adp of the SNF | Individual | 04/01/2019 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- When is the care plan meeting, and can family attend it?Inspectors cited 3 problems in this area, most recently on July 30, 2025: "Ensure each resident receives an accurate assessment."
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 3 problems in this area, most recently on April 3, 2024: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
- Can we see a week of menus and the kitchen, and how are special diets handled?Inspectors cited 2 problems in this area, most recently on April 3, 2024: "Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards."
- How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 1 problem in this area, most recently on July 30, 2025: "Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.24 hours per resident per day, below the Tennessee average of 3.31.
- How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.
Other nursing homes nearby
- Southern Tenn Medical Center SNF Winchester, 0.3 mi · 1 of 5 stars · 11 citations
- Heritage Place Care & Rehabilitation LLC Winchester, 0.7 mi · 1 of 5 stars · 6 citations
- Signature Healthcare of Monteagle Rehab & Wellness Monteagle, 15.7 mi · 3 of 5 stars · 20 citations
- NHC Healthcare, Tullahoma Tullahoma, 15.8 mi · 3 of 5 stars · 13 citations
- Life Care Center of Tullahoma Tullahoma, 16 mi · 2 of 5 stars · 7 citations
- Lynchburg Nursing Center Lynchburg, 17.5 mi · 5 of 5 stars · 6 citations
- Legacy Health and Rehab Manchester, 20.1 mi · 2 of 5 stars · 24 citations
- Manchester Center for Rehabilitation and Healing L Manchester, 22.2 mi · 4 of 5 stars · 12 citations
Tennessee contacts for a concern about a nursing home
These are the official offices in Tennessee. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Tennessee Health Facilities Commission, Division of Licensure and Regulation, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Tennessee Long-Term Care Ombudsman, Department of Disability and Aging, 877-236-0013. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
Common questions
- What is Elk River Health & Nursing Center of Winchester's Medicare star rating?
- CMS rates Elk River Health & Nursing Center of Winchester 3 out of 5 stars overall, with 4 for health inspections, 1 for staffing and 2 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Elk River Health & Nursing Center of Winchester get at its last inspection?
- 3 health deficiencies at the standard inspection on July 30, 2025. The Tennessee average is 4.4.
- Has Elk River Health & Nursing Center of Winchester been fined?
- CMS lists no fines in the last three years.
- Does Elk River Health & Nursing Center of Winchester accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Elk River Health & Nursing Center of Winchester?
- CMS lists 31 owners and managers, and links the home to Twin Rivers Health & Rehabilitation. Legal business name: ELK RIVER HEALTH & NURSING CENTER OF WINCHESTER, LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.