01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-09-10 | 2 | 2025-09-10 | 7 |
| Cycle 2 | 2024-07-11 | 2 | 2024-07-11 | 6 |
| Cycle 3 | 2022-04-20 | 4 | 2022-04-20 | 1 |
CMS CCN 4453202026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Elk River Health & Rehabilitation Of Fayetteville
4081 Thornton Taylor Parkway · Fayetteville, TN 37334 · Lincoln County
Certified beds79CMS provider file
Recent citation rows22current 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
22 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 3 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-09-10 · 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 · 2025-10-152025-09-10 · 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 · 2025-10-152025-09-10 · 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 · 2025-10-152025-09-10 · 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 · 2025-10-152025-09-10 · 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 · 2025-10-152025-09-10 · 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 · 2025-09-192025-09-10 · FIREK0222Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-10-152025-09-10 · FIREK0353Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-10-152025-09-10 · 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 · 2025-10-152024-07-11 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2024-08-202024-07-11 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2024-08-20 · complaint2024-07-11 · 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 · 2024-08-202024-07-11 · FIREK0324Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2024-08-202024-07-11 · FIREK0521Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2024-08-202024-07-11 · 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 · 2024-08-202024-07-11 · 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 · 2024-08-202024-07-11 · FIREK0920Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Correction field: Deficient, Provider has date of correction · 2024-08-202022-04-20 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2022-05-132022-04-20 · 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 · 2022-05-132022-04-20 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2022-05-132022-04-20 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2022-05-132022-04-20 · FIREK0222Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2022-05-1303 / 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 04/01/2019
- BURTON, WILLIAMIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/01/2019
- KUPCHYNSKY, KATHLEENIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 02/07/2024
- PHILLIPS, DOROTHYIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/01/2019
- SHEEHAN, JOHNIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 02/07/2024
- SHEEHAN, MARGARETIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/01/2019
- SMITH, FRANKIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/01/2019
- SHEEHAN, JOHNIndividual · CORPORATE OFFICERNOT APPLICABLE · since 02/07/2024
- 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 04/01/2019
- BURTON, WILLIAMIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2019
- 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
- PHILLIPS, DOROTHYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2019
- SHEEHAN, JOHNIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/07/2024
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 hours3.41per resident day
RN hours0.39per resident day
Weekend nurse hours3.23per resident day
Staff turnover63.2%CMS reported field
06 / LOCAL RECORDS
Open the Fayetteville ledger →