Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
ELK RIVER HEALTH & NURSING CENTER OF WINCHESTER
WINCHESTER, TN · 80 certified beds · Last Life Safety survey July 30, 2025
CMS Certification Number 445319 · first certified October 1993
Ownership
Operated by TWIN RIVERS HEALTH & REHABILITATION · Non profit - Other
- Ownership changed April 1, 2019 (change of ownership)to ELK RIVER HEALTH & NURSING CENTER OF WINCHESTER, LLC from WINCHESTER HEALTHCARE, LLC
Position within TN
26 citations — more than 96% of the 303 certified nursing homes in TN. Compared within TN rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 17 citations; the earlier surveys on file averaged 4.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: October 2026 to April 2029. This facility’s last Life Safety survey was July 2025. Facilities in TN are typically surveyed 15–44 months after the last one (median 32), measured over 322 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to about three years in Virginia. How the window is measured
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Emergency preparedness
17 of the 26 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
How that compares
Compared with the median facility in TN, and nationally. Surveyors differ markedly between states, so the TN figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 26 |
| Median facility in TN | 8 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| December 14, 2021 | 5 |
| April 3, 2024 | 4 |
| July 30, 2025 | 17 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0026 | Establish roles under a Waiver declared by secretary. | 2 | 2025-07-30 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 2 | 2025-07-30 |
| E-0034 | Provide a means of sharing information on occupancy/needs. | 2 | 2025-07-30 |
| E-0033 | Establish methods for sharing information. | 2 | 2024-04-03 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 1 | 2025-07-30 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2024-04-03 |
| K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | 1 | 2025-07-30 |
| E-0020 | Establish policies and procedures including evacuation. | 1 | 2021-12-14 |
What the citations cover
- Emergency Preparedness Deficiencies 17
- Smoke Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Miscellaneous Deficiencies 2
- Other 1
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 17 |
| Smoke Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Miscellaneous Deficiencies | 2 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
July 30, 2025 — 17 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (September 13, 2025) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (September 13, 2025) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (September 13, 2025) |
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (September 13, 2025) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (September 13, 2025) |
| E-0032 | Provide primary/alternate means for communication. | Deficient, Provider has date of correction (September 13, 2025) |
| E-0034 | Provide a means of sharing information on occupancy/needs. | Deficient, Provider has date of correction (September 13, 2025) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (September 13, 2025) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (September 13, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (September 13, 2025) |
| K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Deficient, Provider has date of correction (September 13, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (September 13, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (September 13, 2025) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (September 13, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (September 13, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 13, 2025) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (September 13, 2025) |
April 3, 2024 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (April 26, 2024) |
| E-0033 | Establish methods for sharing information. | Deficient, Provider has date of correction (April 26, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (April 26, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (April 26, 2024) |
December 14, 2021 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (January 5, 2022) |
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (January 5, 2022) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (January 5, 2022) |
| E-0033 | Establish methods for sharing information. | Deficient, Provider has date of correction (January 5, 2022) |
| E-0034 | Provide a means of sharing information on occupancy/needs. | Deficient, Provider has date of correction (January 5, 2022) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.