01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-07-30 | 3 | 2025-07-30 | 17 |
| Cycle 2 | 2024-04-03 | 5 | 2024-04-03 | 4 |
| Cycle 3 | 2021-12-14 | 1 | 2021-12-14 | 5 |
CMS CCN 4453192026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Elk River Health & Nursing Center Of Winchester
32 Memorial Drive · Winchester, TN 37398 · Franklin County
Certified beds80CMS provider file
Recent citation rows35current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
35 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 4 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-07-30 · FIREE0004Severity D · isolated; potential for more than minimal harm
Emergency Preparedness Deficiencies
Develop and maintain an Emergency Preparedness Program (EP).
Correction field: Deficient, Provider has date of correction · 2025-09-132025-07-30 · FIREE0006Severity D · isolated; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct risk assessment and an All-Hazards approach.
Correction field: Deficient, Provider has date of correction · 2025-09-132025-07-30 · FIREE0015Severity D · isolated; potential for more than minimal harm
Emergency Preparedness Deficiencies
Address subsistence needs for staff and patients.
Correction field: Deficient, Provider has date of correction · 2025-09-132025-07-30 · FIREE0024Severity D · isolated; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish policies and procedures for volunteers.
Correction field: Deficient, Provider has date of correction · 2025-09-132025-07-30 · FIREE0026Severity D · isolated; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish roles under a Waiver declared by secretary.
Correction field: Deficient, Provider has date of correction · 2025-09-132025-07-30 · FIREE0032Severity D · isolated; potential for more than minimal harm
Emergency Preparedness Deficiencies
Provide primary/alternate means for communication.
Correction field: Deficient, Provider has date of correction · 2025-09-132025-07-30 · FIREE0034Severity D · isolated; potential for more than minimal harm
Emergency Preparedness Deficiencies
Provide a means of sharing information on occupancy/needs.
Correction field: Deficient, Provider has date of correction · 2025-09-132025-07-30 · FIREE0035Severity D · isolated; potential for more than minimal harm
Emergency Preparedness Deficiencies
Provide family notifications of emergency plan.
Correction field: Deficient, Provider has date of correction · 2025-09-132025-07-30 · FIREE0037Severity D · isolated; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish staff and initial training requirements.
Correction field: Deficient, Provider has date of correction · 2025-09-132025-07-30 · FIREE0039Severity D · isolated; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2025-09-132025-07-30 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2025-08-30 · complaint2025-07-30 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2025-08-302025-07-30 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2025-08-302025-07-30 · FIREK0232Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Correction field: Deficient, Provider has date of correction · 2025-09-132025-07-30 · FIREK0321Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-09-132025-07-30 · FIREK0372Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2025-09-132025-07-30 · FIREK0741Severity D · isolated; potential for more than minimal harm
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Correction field: Deficient, Provider has date of correction · 2025-09-132025-07-30 · FIREK0761Severity D · isolated; potential for more than minimal harm
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Correction field: Deficient, Provider has date of correction · 2025-09-132025-07-30 · FIREK0918Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2025-09-132025-07-30 · FIREK0921Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure that testing and maintenance of electrical equipment is performed.
Correction field: Deficient, Provider has date of correction · 2025-09-132024-04-03 · FIREE0030Severity D · isolated; potential for more than minimal harm
Emergency Preparedness Deficiencies
List the names and contact information of those in the facility.
Correction field: Deficient, Provider has date of correction · 2024-04-262024-04-03 · FIREE0033Severity D · isolated; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish methods for sharing information.
Correction field: Deficient, Provider has date of correction · 2024-04-262024-04-03 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2024-05-032024-04-03 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-05-0303 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- BRADLEY, DONIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 02/07/2024
- BURTON, WILLIAMIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 02/07/2024
- KUPCHYNSKY, KATHLEENIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 02/07/2024
- PHILLIPS, DOROTHYIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 02/07/2024
- SHEEHAN, JOHNIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 02/07/2024
- SHEEHAN, MARGARETIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 12/15/2022
- SMITH, FRANKIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 02/07/2024
- SHEEHAN, JOHNIndividual · CORPORATE OFFICERNOT APPLICABLE · since 02/07/2024
- SHEEHAN, MARGARETIndividual · CORPORATE OFFICERNOT APPLICABLE · since 12/15/2022
- OCOEE FOUNDATION INCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2019
- PIONEER CONSULTING LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2019
- TWIN RIVERS HEALTH & REHABILITATION LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2019
- BRADLEY, DONIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/07/2024
- BURTON, WILLIAMIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/07/2024
- DAVIS, CLINTONIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2019
- HOLCOMBE, MICHELLEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2019
- KUPCHYNSKY, KATHLEENIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/07/2024
- MALIN, DOUGLASIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/28/2024
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.70per resident day
RN hours0.56per resident day
Weekend nurse hours3.24per resident day
Staff turnover69.7%CMS reported field
06 / LOCAL RECORDS
Open the Winchester ledger →