Johnson City, TN

Agape Rehabilitation & Nursing Center, A Waters Cm

4-star overall rating with 3-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

505 N Roan Street, Johnson City, TN

(423) 975-2000

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

84

Certified beds

Average residents

65

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Infinity Healthcare Consulting

Operator or chain grouping

Approved since

1983-11-28

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

70 facilities

Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.68

Registered nurse staffing · state 0.61 · national 0.68

LPN hours / resident day

0.67

Licensed practical nurse staffing · state 1.09 · national 0.87

Aide hours / resident day

2.14

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

3.49

All reported nurse hours · state 3.85 · national 3.89

Licensed hours

1.35

RN + LPN hours · state 1.70 · national 1.54

Weekend hours

3.24

Weekend nurse staffing · state 3.34 · national 3.43

Weekend RN hours

0.81

Weekend registered nurse coverage · state 0.40 · national 0.47

Physical therapist

0.02

Reported PT staffing · state 0.08 · national 0.07

Adjusted RN hours

0.51

CMS adjusted RN staffing hours

Adjusted total hours

2.63

CMS adjusted total nurse staffing hours

Case-mix index

1.82

Higher values indicate more complex resident acuity

RN turnover

36%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

46%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,839

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

18.92

Composite VBP score used to determine payment impact.

Payment multiplier

0.9821

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

3.78

Baseline 53.97% · Performance 48.21% · Measure score 3.78 · Achievement 3.78 · Improvement 1.48

Adjusted total nurse staffing

0

Baseline 2.43 hours · Performance 2.51 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.83%	10.72% 1.1 pts worse	No Different than the National Rate · Eligible stays 37 · Observed rate 18.92% · Lower 95% interval 7.51%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	1.34	1.02 0.3 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 21 · Denominator 21
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 21
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 21 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 81
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	74.0%	89.9% 15.9 pts worse	93.4% 19.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 64.6% · Q2 64.1% · Q3 73.8% · Q4 95.0% · 4Q avg 74.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	95.6%	94.5% 1.1 pts better	95.5% 0.1 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 95.6%
Percentage of long-stay residents experiencing one or more falls with major injury	1.6%	3.6% 2 pts better	3.3% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 1.6% · Q4 3.3% · 4Q avg 1.6% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	66.2%	11.8% 54.4 pts worse	11.4% 54.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 74.2% · Q2 69.5% · Q3 69.2% · Q4 50.0% · 4Q avg 66.2%
Percentage of long-stay residents who lose too much weight	5.8%	6.2% 0.4 pts better	5.4% 0.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 7.4% · Q3 3.8% · Q4 8.3% · 4Q avg 5.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	44.8%	32.2% 12.6 pts worse	19.6% 25.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 35.8% · Q2 40.7% · Q3 50.9% · Q4 52.0% · 4Q avg 44.8%
Percentage of long-stay residents who received an antipsychotic medication	12.9%	18.1% 5.2 pts better	16.7% 3.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 6.5% · Q3 16.7% · Q4 18.9% · 4Q avg 12.9% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	1.5%	19.9% 18.4 pts better	16.3% 14.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.5% · 4Q avg 1.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	0.0%	15.3% 15.3 pts better	14.9% 14.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.9% 0.9 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	1.9% 1.9 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	8.7%	20.2% 11.5 pts better	19.8% 11.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 9.1% · Q3 9.2% · Q4 11.9% · 4Q avg 8.7%
Percentage of long-stay residents with pressure ulcers	2.9%	5.4% 2.5 pts better	5.1% 2.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 3.5% · Q3 3.6% · Q4 3.3% · 4Q avg 2.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	74.1%	79.6% 5.5 pts worse	81.7% 7.6 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 65.1% · Q2 71.4% · Q3 76.3% · Q4 85.2% · 4Q avg 74.1%
Percentage of short-stay residents who newly received an antipsychotic medication	2.2%	1.6% 0.6 pts worse	1.6% 0.6 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 0.0% · Q3 2.6% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	76.1%	79.8% 3.7 pts worse	79.7% 3.6 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 76.1%

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-02-22 · Fire 2024-02-22

5 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

2 fire-safety deficiencies

Top issue: Services (1 deficiency)

Cycle 2 Health 2021-07-20 · Fire 2021-07-20

0 health deficiencies

No concentrated health issue counts in this cycle.

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2019-03-26 · Fire 2019-03-26

3 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2024-02-22

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-02-23

D · Potential for more than minimal harm 2024-02-22

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-02-23

D · Potential for more than minimal harm 2019-03-26

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-04-04

Inspection history

Recent health citations

F · Potential for more than minimal harm 2024-02-22

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-03-08

D · Potential for more than minimal harm 2024-02-22

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-03-08

D · Potential for more than minimal harm 2024-02-22

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2024-03-08

D · Potential for more than minimal harm 2024-02-22

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2024-03-08

D · Potential for more than minimal harm 2024-02-22

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2024-03-08

D · Potential for more than minimal harm 2023-03-29

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2023-04-05

F · Potential for more than minimal harm 2019-03-26

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2019-04-04

D · Potential for more than minimal harm 2019-03-26