Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elk River Health & Nursing Center Of Winchester during CMS and state inspections, most recent first.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with anoxic brain damage and vegetative state had a PEG tube used as the primary means of nutrition, hydration, and medication, with enteral feeding and water flush orders in place. Although the resident could not complete BIMS due to severe cognitive impairment and was observed receiving tube feeding via pump, the annual MDS did not code the PEG tube use. The MDS Coordinator and DON both confirmed the assessment was inaccurate.
Failure to revise care plan for multiple changes in condition. A resident with liver cirrhosis, DM, and schizophrenia returned from a hospital stay for an acute GI bleed requiring transfusion and stopping anticoagulants, but the care plan was not updated. The record also showed a new right retinal detachment with planned eye surgery, otitis media treated with cefdinir, and a right testicular lesion/mass suspected to be cancer, yet these changes were not reflected in the care plan. The DON confirmed the omissions.
Improper sealing of food items and unsanitary kitchen conditions were observed, potentially affecting 57 out of 58 residents. Open containers of various food items were found in the food preparation room and dry storage area. The kitchen entry door area exhibited dirt-like debris, chipped drywall, and accumulated dirt and food debris. The Certified Dietary Manager acknowledged the improper storage and need for deep cleaning, while the Maintenance Director confirmed the unsatisfactory condition of the kitchen entry door.
The facility failed to implement comprehensive care plans for two residents, leading to deficiencies in fall prevention and adaptive eating utensils. Observations and staff interviews revealed that prescribed interventions were not consistently applied, compromising the residents' well-being.
The facility failed to follow physician's orders for two residents, leading to deficiencies in their care. One resident did not have the prescribed fall interventions, and another did not receive the adaptive eating utensils and non-slip product required for self-feeding. Staff interviews and observations confirmed these lapses, which were acknowledged by the Director of Nursing.
A facility failed to follow its tracheostomy care policy and physician's order for a resident with severe cognitive impairment and multiple diagnoses. An LPN did not remove the resident's neck ties or replace the soiled tracheostomy collar during care, as required. The deficiency was confirmed through interviews with the DON and the LPN.
The facility failed to properly contain garbage and refuse in two dumpsters, as required by their policy. Both dumpsters lacked intact drain plugs, exposing waste to air, elements, and potential pests. The Certified Dietary Manager confirmed the issue during an interview.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Inaccurate MDS Coding for PEG Tube Use
Penalty
Summary
The facility failed to accurately complete the MDS assessment for one resident who was admitted and re-admitted with diagnoses including diabetes mellitus, anoxic brain damage, and vegetative state, and who had a PEG tube for nutrition and medication. The facility policy required resident assessments to be conducted and submitted in accordance with federal and state timeframes, and the RAI Manual 3.0 states that the feeding tubes CAA is triggered when a resident has a need for a feeding tube for nutrition. The medical record showed the resident had physician orders for enteral feeding via PEG tube, including Jevity 1.2 cal at 50 ml per hour for 22 hours daily with water flushes, and the care plan identified tube feedings related to anoxic brain injury. The annual MDS assessment showed the resident could not complete a BIMS due to severe cognitive impairment, but the PEG tube use was not coded on the assessment. During observations, the resident was seen lying in bed with the head of the bed elevated while the PEG tube was infusing via pump with Jevity 1.2 cal and water flushes. The MDS Coordinator stated the resident required the PEG tube as the primary means of nutrition, hydration, and medication, and the DON confirmed the MDS was inaccurately assessed and coded.
Failure to Revise Care Plan for Multiple Changes in Condition
Penalty
Summary
The facility failed to revise the comprehensive care plan for one resident after multiple changes in condition and treatment needs. Resident #3 was admitted with diagnoses including liver cirrhosis, peptic ulcer disease, diabetes, and schizophrenia, and later returned to the facility after a hospitalization for an acute gastrointestinal bleed that required a blood transfusion and discontinuation of anticoagulant medication. The current comprehensive care plan, dated 10/19/2024, did not include the liver cirrhosis diagnosis and had no documentation showing it was revised after the GI bleed hospitalization, the monitoring and treatment needs related to that event, or the discontinuation of anticoagulant therapy. The record also showed additional new conditions and treatments that were not reflected in the care plan. A vision order identified a right retinal detachment and requested referral to a retinal specialist, with later notes showing discussion of eye surgery and scheduling of the procedure, but the care plan was not revised to include the retinal detachment or pending surgery. In addition, the resident reported bloody drainage from the right ear and was started on cefdinir for otitis media, and an ultrasound of the scrotum showed a lesion in the right testicle with later notes describing a testicular mass suspected to be testicular cancer. The care plan revised on 7/30/2025 still did not document revisions for the ear infection treatment or the new testicular mass diagnosis. During interview, the DON confirmed the care plan had not been revised to include these diagnoses and treatments.
Deficiencies in Food Storage and Kitchen Cleanliness
Penalty
Summary
The facility failed to ensure proper sealing of food items and maintain a sanitary kitchen environment, potentially affecting 57 out of 58 residents. Observations on 4/1/2024 revealed open containers of various food items in the food preparation room and dry storage area, including garlic powder, celery seed, mesquite seasoning, rubbed sage, and instant grits. Additionally, the kitchen entry door area exhibited unsanitary conditions with dirt-like debris, chipped drywall, and accumulated dirt and food debris in the crevices. During interviews, the Certified Dietary Manager acknowledged the improper storage of food items and the need for deep cleaning of the kitchen floors. The Maintenance Director confirmed the unsatisfactory condition of the kitchen entry door, indicating a lack of maintenance in ensuring a sanitary and good-working environment. These observations highlight deficiencies in food storage practices and kitchen cleanliness, posing potential risks to resident health and safety.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for two residents, leading to deficiencies in their care. Resident #19, who was admitted with diagnoses including Parkinsonism and repeated falls, experienced multiple falls due to the facility's failure to implement prescribed interventions. Despite recommendations to place floor mats on both sides of the bed and a non-slip product in the wheelchair seat, observations revealed that these measures were not consistently applied. Interviews with staff confirmed that these interventions were not routinely implemented, leading to the resident's continued risk of falls. Similarly, Resident #46, who required assistance with personal care and had conditions such as osteoarthritis and dementia, did not receive the adaptive eating utensils and non-slip products as outlined in their care plan. Observations during meal times showed that the resident was using regular utensils and did not have a non-slip product under their food bowls, contrary to the physician's orders. Interviews with staff revealed a lack of awareness and inconsistent application of these prescribed interventions, which were intended to maximize the resident's independence with self-feeding. The Director of Nursing confirmed that the comprehensive care plans for both residents were not fully implemented, resulting in deficiencies in their care. The failure to adhere to the care plans and provide the necessary adaptive equipment and safety measures compromised the residents' well-being and highlighted gaps in the facility's adherence to its own policies and procedures.
Failure to Follow Physician's Orders for Fall Interventions and Adaptive Eating Utensils
Penalty
Summary
The facility failed to follow physician's orders for two residents, leading to deficiencies in their care. Resident #19, who was admitted with diagnoses including Parkinsonism and repeated falls, had specific orders for fall interventions. Despite orders for floor mats to be placed on both sides of the bed and a non-slip product to be added to the wheelchair seat, observations on multiple occasions revealed that these interventions were not consistently implemented. Interviews with staff, including a CNA and the Director of Therapy, confirmed that these orders were not followed, and the Director of Nursing acknowledged the failure to adhere to the physician's orders. Resident #46, admitted with diagnoses including the need for assistance with personal care, osteoarthritis, dementia with agitation, and lack of coordination, also experienced a failure in the implementation of physician's orders. The resident's care plan and physician's orders specified the use of built-up utensils and a non-slip product under food bowls to maximize independence with self-feeding. However, observations during meals showed that the resident was using regular utensils and did not have the non-slip product under the bowls. Interviews with the CNA, Director of Therapy, and Dietary Manager confirmed that these orders were not being followed, and the Director of Nursing acknowledged the deficiency. These failures to follow physician's orders for both residents highlight significant lapses in the facility's adherence to prescribed care plans. The lack of proper fall interventions for Resident #19 and the absence of adaptive eating utensils for Resident #46 indicate a broader issue of non-compliance with physician directives, which could potentially impact the residents' safety and quality of care.
Failure to Follow Tracheostomy Care Protocol
Penalty
Summary
The facility failed to provide tracheostomy care according to its policy and the physician's order for a resident with severe cognitive impairment and multiple diagnoses, including Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure. The facility's policy required the removal and replacement of neck ties and the tracheostomy collar during tracheostomy care. However, during an observation, an LPN performed tracheostomy care but did not remove the resident's neck ties or replace the soiled tracheostomy collar, contrary to the facility's policy and the physician's order. The deficiency was confirmed through interviews with the Director of Nursing and the LPN involved. The Director of Nursing stated that it was her expectation for the nursing staff to follow the facility's policy and physician orders related to tracheostomy care. The LPN admitted to not applying fresh neck ties or replacing the soiled tracheostomy collar during the care procedure. This failure to adhere to the established tracheostomy care protocol was identified during a survey and was documented as a deficiency in the facility's care practices.
Improper Garbage Containment in Dumpsters
Penalty
Summary
The facility failed to ensure garbage and refuse were properly contained in two dumpsters (A and B). The facility's policy on food-related garbage and refuse disposal, dated 10/2017, required that garbage and refuse containing food wastes be stored in a manner inaccessible to pests and kept closed and free of surrounding litter. During an observation of the outside dumpster area, it was noted that both dumpsters lacked intact drain plugs, leaving open areas approximately the size of a half dollar. This condition exposed the waste contents to air, elements, and potential pests. The Certified Dietary Manager confirmed the missing drain plugs and improper containment of garbage during an interview.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 47 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Winchester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southern Tenn Medical Center Snf | 0.3 mi | ★★★★★ | 22 | 0 |
| Heritage Place Care & Rehabilitation Llc | 0.7 mi | ★★★★★ | 0 | 0 |
| Signature Healthcare Of Monteagle Rehab & Wellness | 15.7 mi | ★★★★★ | 14 | 0 |
| Nhc Healthcare, Tullahoma | 15.8 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Tullahoma | 16 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.