Ocoee Transitional Care Center LLC
2320 East Lamar Alexander Pkwy, Maryville, TN 37804 · Blount County · 76 certified beds · avg 66 residents/day · certified since Oct 3, 1997
Part of chain: TWIN RIVERS HEALTH & REHABILITATION (11 facilities, chain avg rating 3.9★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
⚠ The most recent standard health inspection was more than 2 years ago — conditions may have changed.
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
All citations in the current public record (17)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jan 22, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jan 22, 2026 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Jan 22, 2026 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Jan 22, 2026 | D · Potential for harm, one-off | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · from a complaint |
| Aug 17, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 17, 2023 | E · Potential for harm, repeated | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Aug 17, 2023 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Aug 17, 2023 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Aug 17, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Aug 17, 2023 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Aug 17, 2023 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Aug 17, 2023 | D · Potential for harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. |
| Aug 17, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 15, 2020 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jan 15, 2020 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Dec 12, 2018 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Dec 12, 2018 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (2 → 9).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2018 | 2 | 0 | E |
| 2020 | 2 | 0 | E |
| 2023 | 9 | 0 | F |
| 2026 | 4 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Tennessee avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.84 | 3.62 | 3.95 | top 29% in Tennessee; top 46% in the U.S. |
| Registered Nurse hours | 1.01 | 0.57 | 0.69 | top 6% in Tennessee; top 15% in the U.S. |
| Weekend total nurse staffing | 3.27 | 3.15 | 3.50 | top 32% in Tennessee; bottom 46% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.59 | 0.39 | 0.48 | top 12% in Tennessee; top 23% in the U.S. |
| Total nursing staff turnover (%) | 50.0 | 48.9 | 45.8 | top 50% in Tennessee; bottom 38% in the U.S. |
| RN turnover (%) | 33.3 | 43.2 | 42.9 | top 30% in Tennessee; top 33% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.36, RN 1.15, weekend 3.70. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: —/5 · short-stay residents: 4/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Bradley, Don | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Burton, William | Individual | Managing Control - Governing Body | NOT APPLICABLE | 02/07/2024 |
| Burton, William | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Cunliffe, Joseph | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2024 |
| Davis, Clinton | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/18/2024 |
| Davis, Clinton | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 08/22/2025 |
| Davis, Clinton | Individual | ADP of the SNF | NOT APPLICABLE | 06/18/2024 |
| Functional Pathways of Tennessee LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
| Guardian Pharmacy of Knoxville, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
| Holcombe, Michelle | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Holcombe, Michelle | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
| Hunt, Billy | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/06/2025 |
| Hunt, Billy | Individual | ADP of the SNF | NOT APPLICABLE | 01/06/2025 |
| Kupchynsky, Kathleen | Individual | Managing Control - Governing Body | NOT APPLICABLE | 02/07/2024 |
| Kupchynsky, Kathleen | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/07/2025 |
| Ocoee Foundation INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Ocoee Foundation INC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
| Ocoee Tcc-Mvv Propco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
| Phillips, Dorothy | Individual | Managing Control - Governing Body | NOT APPLICABLE | 02/07/2024 |
| Phillips, Dorothy | Individual | Corporate Director | NOT APPLICABLE | 02/07/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "How does your quality committee work, and can you give an example of a problem it recently identified and fixed?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "If you ever planned to discharge or transfer my family member, how much written notice would we receive and how could we appeal?"
- "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Asbury Place at Maryville | 1.0 mi | Maryville, TN | ★☆☆☆☆ | 2/5 | abuse |
| Fairpark Health and Rehabilitation | 1.9 mi | Maryville, TN | ★★☆☆☆ | 1/5 | |
| Shannondale of Maryville Health Care Center | 2.4 mi | Maryville, TN | ★★★★★ | 4/5 | |
| Foothills Transitional Care and Rehabilitation | 2.9 mi | Maryville, TN | ★★☆☆☆ | 2/5 | |
| Life Care Center of Blount County | 6.8 mi | Louisville, TN | ★★★☆☆ | 2/5 | |
| Lyonsview Health and Rehabilitation Center | 12.2 mi | Knoxville, TN | ★☆☆☆☆ | 1/5 | SFF |
| NHC Healthcare, Farragut | 12.8 mi | Knoxville, TN | ★★★★★ | 4/5 | |
| Fort Sanders Tcu | 13.9 mi | Knoxville, TN | ★★★★☆ | 4/5 | |
| NHC Healthcare, Ft Sanders | 14.0 mi | Knoxville, TN | ★★★☆☆ | 2/5 | |
| West Hills Health and Rehab | 14.0 mi | Knoxville, TN | ★★★☆☆ | 4/5 | |
| Legacy Park Health and Rehabilitation | 14.1 mi | Knoxville, TN | ★☆☆☆☆ | 2/5 | |
| Wellpark Health and Rehabilitation | 14.1 mi | Knoxville, TN | ★★★☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 445404.