Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 & Rehabilitation Of Fayetteville during CMS and state inspections, most recent first.
MDS assessments were inaccurately completed for two residents by coding clopidogrel as an anticoagulant even though no anticoagulant was ordered or administered, and for two other residents by failing to code PASRR Level II status despite documented serious mental illness and PASRR Level 2 outcomes. The MDS Coordinator confirmed the assessments were inaccurate.
A resident with Parkinson’s Disease, DM, HTN, and severe cognitive impairment had an MDS showing partial/moderate assistance with eating, but the care plan still stated the resident was independent with eating. A CNA and an LPN stated the resident was dependent on staff for eating, and the LPN MDS Coordinator and DON confirmed the care plan had not been revised to reflect the resident’s current eating assistance needs.
The facility failed to properly clean and sanitize the ice machine and did not store milk at the appropriate temperature, increasing the risk of foodborne illness. The Dietary Manager found milk stored at 45°F, above the required 41°F. The ice machine had yellow stains and dark specks, indicating inadequate maintenance. The Maintenance Director, responsible for quarterly cleaning, was not informed of the issue until the state survey, and the last service was in early June. The Administrator expects staff to report maintenance needs.
A facility failed to maintain accurate medical records for a resident's controlled drug administration. An LPN did not sign out Gabapentin and Percocet after administering them, contrary to facility policy. The discrepancy was noted during a narcotic count, and the LPN admitted to the oversight, which was confirmed by a pharmacist.
Inaccurate MDS Coding for Anticoagulant Use and PASRR Level II Status
Penalty
Summary
The facility failed to accurately complete MDS assessments for four residents. For Resident #1 and Resident #29, the MDS assessments incorrectly coded anticoagulant use even though the medical record showed each resident had orders for clopidogrel and, in Resident #1’s case, aspirin, but no order for an anticoagulant medication and no anticoagulant administration documented on the MAR. Resident #1 had diagnoses including vascular dementia, diabetes, and a history of stroke with paralysis, and Resident #29 had diagnoses including vascular dementia, traumatic subarachnoid hemorrhage, and history of transient ischemic attack. The facility also failed to accurately code PASRR Level II status for Resident #6 and Resident #28. Resident #6 was admitted and readmitted with diagnoses including anxiety disorder, major depressive disorder, and schizoaffective disorder, bipolar type, and had a PASRR Level 2 outcome related to serious mental illness, but the annual MDS did not code the PASRR Level 2 outcome despite a BIMS score of 12. Resident #28 had diagnoses including bipolar disorder and depression, had a PASRR Level 2 outcome related to serious mental illness, and the annual MDS did not code the PASRR Level 2 outcome despite a BIMS score of 14. During interview, the MDS Coordinator stated that Residents #1 and #29 had not received an anticoagulant medication and Residents #6 and #28 had a serious mental illness, and confirmed the assessments were inaccurate.
Care Plan Not Revised for Changed Eating Assistance Needs
Penalty
Summary
The facility failed to revise the comprehensive care plan for one resident after the resident’s condition and care needs changed. Resident #27 was admitted with diagnoses including Parkinson’s Disease, diabetes, and hypertension, and the quarterly MDS assessment showed a BIMS score of 00, indicating severe cognitive impairment. The assessment also showed the resident required partial/moderate assistance with eating, but the comprehensive care plan revised 8/15/2025 stated the resident was independent with eating at that time. During interviews, a CNA stated Resident #27 was dependent on staff for eating, and an LPN also stated the resident was dependent on staff for eating. The LPN MDS Coordinator confirmed the care plan had not been revised to reflect that the resident was dependent on staff with eating, and the DON also confirmed the care plan had not been revised to reflect this change.
Improper Food Storage and Ice Machine Maintenance
Penalty
Summary
The facility failed to minimize the potential for foodborne illness transmission by not properly cleaning and sanitizing the inner components of the ice machine and by not storing milk at the appropriate temperature. The Dietary Manager (DM) conducted a temperature check on a carton of milk in the cooler and found it to be at 45 degrees Fahrenheit, which is above the required 41 degrees Fahrenheit. The DM confirmed that the milk's temperature should be at or below 41 degrees Fahrenheit. Additionally, the ice machine on the 200 Hall was observed to have yellow stains on the inside cover panel with dark specks on the bottom of the panel dripping into the ice. The Maintenance Director stated that he is responsible for cleaning and checking the ice machine every three months and relies on the facility's staff to notify him if anything is wrong with the ice machine in between scheduled maintenance. However, no one had notified him about the ice machine needing to be cleaned before the state survey. The last service of the ice machine was recorded at the beginning of June 2024. The Administrator expects her staff to notify the Maintenance Director when the ice machine needs to be cleaned or if there are any mechanical issues.
Failure to Maintain Accurate Medical Records for Controlled Drugs
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident regarding the administration of controlled drugs. The facility's policy on controlled substances, dated April 2019, requires that controlled substances be reconciled upon administration, with the nurse responsible for recording the name, strength, dose, time, method of administration, quantity remaining, and their signature. However, during a review of the Medication Administration Record (MAR) for a resident admitted with diagnoses including morbid obesity and muscle weakness, discrepancies were found. The MAR indicated orders for Gabapentin and Percocet, but during a random narcotic drug count, it was discovered that one Gabapentin capsule and one Percocet tablet were not accounted for on the narcotic count sheet. During an observation of medication administration, an LPN admitted to forgetting to sign out the medications after administering them at 7:00 AM. The LPN acknowledged that the narcotics should have been signed out as soon as they were removed for administration. This oversight was confirmed during a telephone interview with the pharmacist, who stated that the nurse should have signed out the narcotics at the time of administration. This failure to adhere to the facility's policy resulted in an incomplete and inaccurate medical record for the resident.
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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.
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Nursing homes near Fayetteville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Donalson Care Center | 2 mi | ★★★★★ | 0 | 0 |
| Lynchburg Nursing Center | 14.6 mi | ★★★★★ | 5 | 0 |
| Elk River Health And Nursing Center Of Ardmore, Ll | 20.5 mi | ★★★★★ | 11 | 0 |
| Nhc Healthcare, Tullahoma | 23.7 mi | ★★★★★ | 0 | 0 |
| The Waters Of Shelbyville, Llc | 23.9 mi | ★★★★★ | 18 | 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.