Woodbury Health and Rehabilitation Center
119 West High Street, Woodbury, TN 37190 · Cannon County · 82 certified beds · avg 78 residents/day · certified since Jan 1, 2002
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: ★★★☆☆3/5 · CMS overall rating: 3/5
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.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Feb 16, 2022 · F-0678
The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes.
Why it matters: In a cardiac or breathing emergency, failure to start CPR promptly can be the difference between life and death.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Mar 9, 2022 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 22, 2026 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 13, 2026 (Deficient, Provider has date of correction)
All citations in the current public record (14)
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 |
|---|---|---|
| Apr 22, 2026 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Nov 25, 2024 | 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. |
| Nov 25, 2024 | F · Potential for harm, facility-wide | 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. |
| Nov 25, 2024 | D · Potential for harm, one-off | The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records. |
| Feb 16, 2022 | ▲ J · Immediate jeopardy, one-off | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. |
| Feb 16, 2022 | 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. |
| Feb 16, 2022 | 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. |
| Feb 16, 2022 | 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. |
| Feb 16, 2022 | 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. |
| Feb 16, 2022 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Feb 16, 2022 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Feb 16, 2022 | 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. |
| Feb 16, 2022 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 16, 2022 | 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. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (3 → 1).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 10 | 1 | J ▲ |
| 2024 | 3 | 0 | F |
| 2026 | 1 | 1 | G ▲ |
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) | 3.22 | 3.62 | 3.95 | bottom 29% in Tennessee; bottom 22% in the U.S. |
| Registered Nurse hours | 0.26 | 0.57 | 0.69 | bottom 5% in Tennessee; bottom 6% in the U.S. |
| Weekend total nurse staffing | 3.06 | 3.15 | 3.50 | top 48% in Tennessee; bottom 34% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.22 | 0.39 | 0.48 | bottom 19% in Tennessee; bottom 17% in the U.S. |
| Total nursing staff turnover (%) | 40.5 | 48.9 | 45.8 | top 25% in Tennessee; top 38% in the U.S. |
| RN turnover (%) | 42.9 | 43.2 | 42.9 | bottom 50% in Tennessee; bottom 49% 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 3.35, RN 0.27, weekend 3.19. Staffing rating: 2/5.
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: 5/5 · short-stay residents: 3/5
Who owns this facility
Non profit - Other
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Ocoee Foundation INC | Organization | Direct Ownership Interest | NOT APPLICABLE | 01/17/2008 |
| Bradley, Don | Individual | Managing Control - Governing Body | NOT APPLICABLE | 02/07/2024 |
| Bradley, Don | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/07/2024 |
| Burton, William | Individual | Managing Control - Governing Body | NOT APPLICABLE | 02/07/2024 |
| Burton, William | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/07/2024 |
| Davis, Clinton | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2019 |
| Davis, Clinton | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2019 |
| Holcombe, Michelle | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2019 |
| Holcombe, Michelle | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2019 |
| Kupchynsky, Kathleen | Individual | Managing Control - Governing Body | NOT APPLICABLE | 02/07/2024 |
| Kupchynsky, Kathleen | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/07/2024 |
| Ocoee Foundation INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/17/2008 |
| Ocoee Foundation INC | Organization | ADP of the SNF | NOT APPLICABLE | 01/17/2008 |
| Phillips, Dorothy | Individual | Managing Control - Governing Body | NOT APPLICABLE | 02/07/2024 |
| Phillips, Dorothy | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/07/2024 |
| Pioneer Consulting LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2019 |
| Pioneer Consulting LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/27/2025 |
| Sheehan, John | Individual | Managing Control - Governing Body | NOT APPLICABLE | 02/07/2024 |
| Sheehan, John | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/07/2024 |
| Sheehan, John | Individual | Trustee of the SNF | NOT APPLICABLE | 06/19/2008 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Are staff on every shift trained and certified in CPR, and how do they know each resident's resuscitation wishes?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How do your actual daily staffing levels compare to what's reported on Medicare's Care Compare website?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "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 |
|---|---|---|---|---|---|
| NHC Healthcare, Smithville | 16.4 mi | Smithville, TN | ★★★☆☆ | 2/5 | |
| NHC Healthcare, Murfreesboro | 17.5 mi | Murfreesboro, TN | ★★★★★ | 5/5 | |
| Stone River Post Acute | 17.8 mi | Murfreesboro, TN | ★★★☆☆ | 3/5 | |
| Community Care of Rutherford | 18.0 mi | Murfreesboro, TN | ★☆☆☆☆ | 1/5 | |
| Adamsplace, LLC | 18.0 mi | Murfreesboro, TN | ★★★☆☆ | 2/5 | |
| Stones River Manor, INC | 18.2 mi | Murfreesboro, TN | ★★★★★ | 4/5 | |
| Tennessee Veterans Home | 18.2 mi | Murfreesboro, TN | ★☆☆☆☆ | 1/5 | |
| NHC Healthcare, McMinnville | 19.2 mi | McMinnville, TN | ★★★★★ | 4/5 | |
| Willow Branch Health and Rehabilitation | 19.5 mi | McMinnville, TN | ★★☆☆☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 445435.