Southern Tennessee Regional Health System Winchest
An acute care hospital in Winchester, Tennessee 37398
185 Hospital Road, Winchester, Tennessee 37398. (931) 967-8200.
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The short answer
Record last released by CMS on Oct 20, 2026.
- 3of 5 CMS’s overall rating
- 3of 5 patient survey rating
- 2 deficiencies cited in the last three years
- 152 beds
Each figure’s source sits beside it, in its section below.
What these words mean3
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
The last inspection on record was on Dec 9, 2025: a complaint inspection.
2 deficiencies cited in the last three years.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
2 deficiencies in 2 months of the last 36. Last cited Dec 2025. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Dec 9, 2025: complaint inspection1 deficiency
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Initial Comments - Not A Deficiency Citation
“A Life Safety Code Complaint Investigation of TN00077066 was conducted by the Tennessee Health Facilities Commission, on 12/09/2025. During this Life Safety Code Complaint Investigation, Southern Tennessee Regional Health Systems Winchester was found in substantial compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 482.41(b), Life Safety from fire, and the related National Fire Protection Association (NFPA) standard 101 (2012 Edition)”
Feb 4, 2025: complaint inspection1 deficiency
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Discharge Planning-Evaluation
The inspectors’ words, 990 words
“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 51389 Based on medical record review and interviews, the facility failed to provide a discharge evaluation for post hospital services for 1 patient (Pt #2) out of 3 patients reviewed. The findings include: Review of the facility policy, “Patient Rights and Responsibilities,” dated 9/2015 showed “...reasonable continuity of care and to be informed of any continuing health care requirements following discharge.” Medical record review of Admission History and Physical dated 2/20/2024 at 11:06 AM, showed Pt #2 was admitted for further evaluation and treatment for Schizophrenia. Pt #2 lived at a nursing facility and the nursing home staff reported “...over the past few weeks the patient has become increasingly more agitated and has been experiencing psychosis. Staff at the facility report she has been refusing care, she has been noncompliant with medication. They report she has been verbally aggressive and has been yelling out. Staff also reports that she has been quite paranoid and delusional...reporting people at the facility are trying to harm her...She has also been neglecting self-care and has refused to bathe.” Medical record review of a Physical Therapy Evaluation on 2/20/2024 at 4:46 PM, showed Pt #2 ambulating with supervision for short distances “according to the nurse...(Pt #2) refused to get up with the therapist.” Review showed there was no documentation physical therapy did an evaluation of Pt #2 prior to her discharge to review for any discharge needs. Medical record review of the Master Treatment Plan dated 2/21/2024 at 10:30 AM, showed Pt #2’s long term and short term goals. The plan included Social Work Interventions which included: “ Assess patient for depression using Geriatric Depression Scale. “ Hold cognitive group 3-5 times/week. “ Family contact 1-2 times/week for education, progress, and support strategies. “ Coordinate discharge and aftercare, including facility placement if indicated. “ Assist patient in creating a safety/crisis plan upon discharge. “ Provide discharge planning that will include help for supervision and medication compliance. Medial record review of Safety Determination Request Form dated 3/18/2024, filled out by SW #1 showed Pt #2 “...is a long-term care resident with an extensive psychiatric history. Patient has limited social support. Patient requires 24/7 care and supervision related to diagnosis of Schizoaffective disorder...Patient is able to ambulate; however, she demonstrates poor safety awareness, poor insight, poor judgement, impulsive behavior, and poor interpretation of the environment placing the patient at increased risk for falls...Patient experiences intermittent incontinence and requires assistance with activities to maintain basic hygiene as well pericare. Patient requires firm boundaries to prevent self-neglect as she frequently refuses to engage in hygiene related activities or to bathe...Patient is unable to live in a community setting due to paranoia, persistent delusional thought. History of medication compliance and risk for self-neglect. Patient currently benefits from a safe and structured environment that allows freedom of movement...Patient requires 24/7 nursing care to ensure that her medical, physical, mental health and self-care needs are maintained and managed. Patient is at increased risk for malnutrition, self-neglect, and medication noncompliance. Patient also demonstrates impaired insight, impaired judgement, and impaired decision-making capacity...Patient has limited caregiver support in the community and relies on nursing home care and support to meet her ongoing needs. Patient has a sister in the community, but she is unable to provide direct care activities for the patient.” Medical record review of Social Worker Notes dated 3/21/2024 through 4/11/2024, showed discharge planning was started. On 3/21/2024, the hospital was notified the patient failed her PASRR (Preadmission Screening and Resident Review, a federal requirement to help ensure appropriate placement in nursing homes for long term care) and was not able to return to the nursing home she had resided in. The plan changed “to focus on group homes and boarding homes.” Continued review showed the hospital was unable to secure housing for Pt #2. Medical record review of Social Worker Notes dated 4/5/2024 at 9:10 AM, showed SW #1 updated Pt #2’s sister on progress, “The sister asked about what the process would be if insurance is unable to provide housing...advised the patient’s sister would be responsible for securing housing post discharge...sister asked ‘so you expect me to take her home with me’...responded yes.....Patients’ sister asked ‘what if I refuse to come and get her?’ The Social Worker’s notes reveal the patients’s sister was advised the hospital’s Risk Management and APS [Adult Protective Services] would be apprised of the situation as she cannot legally abandon her sister at the hospital. The medical record lacked documentation to plan for the patient needs at her sister’s house. Medical record review of Social Worker Notes dated 4/12/2024 at 1:30 PM, showed SW #1 met with Pt #2’s sister. “Patients’ sister cited multiple social issues which will complicate her ability to manage her sister’s care in her home...Patients sister requested chucks to protect her vehicle from possible incontinence during the 2.5 hours’ drive home.” There is no evidence SW #2 discussed with Pt #2’s sister regarding post discharge needs for immediate care. During an interview with Manager of Case Management on 2/4/2025 at 9:00 AM showed the hospital will try “...everything they can do to get placement for a patient who can’t go home...we will try to get help for the family as much as possible...We do everything we can to help them once they get home.” Interview continued and revealed SW #1 was no longer employed by the hospital and the Case Manager confirmed the immediate post discharge needs were not met for Patient #2.”
All 2 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Dec 9, 2025 | Complaint inspection | 1 deficiency cited |
| Feb 4, 2025 | Complaint inspection | 1 deficiency cited |
How do patients fare?
- CMS’s overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System. for it is 3 of 5.
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 0 better and 1 worse of 6; safety of care, 0 better and 0 worse of 4; readmission, 1 better and 0 worse of 8.
- Patients rate it 3 of 5 in CMS’s patient survey (434 surveys completed, Oct 1, 2024 to Sep 30, 2025): 67% rated it 9 or 10 out of 10, and 65% would definitely recommend it.
- Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): catheter urinary tract infections (CAUTI), no different than national benchmark; C. diff infections, better than the national benchmark.
- CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart attack 12.1%, heart failure 9.7%, pneumonia 18.6%, COPD 12.9%, stroke 14.5%. CMS gives no comparison with the national rate for them in this release.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart attack 14.1%, heart failure 20.3%, pneumonia 15.8%, COPD 20.1%, hip or knee replacement 5.6%. CMS gives no comparison with the national rate for them in this release.
- After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
- Emergency department patients spent a median of 145 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 1% left before being seen.
- 47% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
- Medicare’s spending per patient here is 1.01 times the national median (Jan 1, 2024 to Dec 31, 2024).
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | 3 of 5 |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | 3 of 5 |
Is it certified, and in good standing?
- Medicare-certified acute care hospital since Jul 1, 1966.
- Ownership: proprietary.
- It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
- It has an inpatient rehabilitation unit of 12 beds, which CMS lists apart as a rehabilitation facility.
- Proprietary.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- Not among the hospitals whose Medicare payments CMS cut under the Hospital-Acquired Condition Reduction Program for fiscal year 2026.
- 2 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- In CMS’s patient survey, patients rate how well its nurses communicated 4 of 5.
- 50% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- Highpoint Healthcare, LLC owns 100% directly since Feb 28, 2025.
- Lifepoint Corporate Services General Partnership runs it.
- 8 owners or officers are people: William Haugh (corporate officer, 0%); Adam M Martin (runs it (operational or managerial control), 0%); Daniel Davis (corporate officer); Marcus B Poppell (corporate officer); Marcus B Poppell (other role (CMS gives no detail)); Charlotte E Lawrence (corporate officer, 0%); John Michael Grooms (corporate officer); Christopher J Monte (corporate officer).
- CMS’s Provider of Services file records 4 changes of ownership.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| Highpoint Healthcare, LLC | Owns 5% or more directly | 100% | Feb 28, 2025 |
| Lifepoint Holdings 2 LLC | Owns 5% or more through other companies | 80% | Mar 1, 2025 |
| Dsb Acquisition LLC | Owns 5% or more through other companies | 80% | Nov 16, 2018 |
| Lifepoint Hospitals Holdings LLC | Owns 5% or more through other companies | 80% | Dec 31, 2015 |
| Historic Lifepoint Hospitals LLC | Owns 5% or more through other companies | 80% | Jan 1, 1999 |
| Lifepoint Health Inc. | Owns 5% or more through other companies | 80% | Nov 16, 2018 |
| Legacy Lifepoint Health LLC | Owns 5% or more through other companies | 80% | May 8, 2015 |
| Saint Thomas Network | Owns 5% or more through other companies | 20% | Feb 28, 2025 |
| Saint Thomas Health | Owns 5% or more through other companies | 20% | Feb 28, 2025 |
| Ascension Health | Owns 5% or more through other companies | 20% | Feb 28, 2025 |
| Baptist Health Care Affiliates Inc. | Owns 5% or more through other companies | 20% | Feb 28, 2025 |
| Lifepoint Corporate Services General Partnership | Runs it (operational or managerial control) | Jan 1, 2015 |
How does it compare nearby?
- No other hospital CMS lists is in Franklin County.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.