Cycle 1
Health 2023-07-25 · Fire 2023-07-25
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Johnson City, TN
Lakebridge, A Waters Community, LLC
3-star overall rating with 4-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
115 Woodlawn Drive, Johnson City, TN
(423) 975-0095
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
109
Certified beds
Average residents
102
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Infinity Healthcare Consulting
Operator or chain grouping
Approved since
1995-09-26
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
0.27
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.13
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
1.90
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.29
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
2.88
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.17
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.22
CMS adjusted RN staffing hours
Adjusted total hours
2.70
CMS adjusted total nurse staffing hours
Case-mix index
1.67
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,982
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.86
Composite VBP score used to determine payment impact.
Payment multiplier
0.9948
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.65
Baseline 23.69% · Performance 20.93% · Measure score 3.65 · Achievement 1.09 · Improvement 3.65
Healthcare-associated infections
5.20
Baseline 13.04% · Performance 8.46% · Measure score 5.20 · Achievement 0 · Improvement 5.20
Total nurse turnover
6.93
Baseline 42.50% · Performance 35.37% · Measure score 6.93 · Achievement 6.93 · Improvement 3.54
Adjusted total nurse staffing
0.97
Baseline 2.42 hours · Performance 2.91 hours · Measure score 0.97 · Achievement 0 · Improvement 0.97
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.6% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 56 · Observed rate 12.5% · Lower 95% interval 6.95% |
| Discharge to community | 49.71% |
50.57%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 42.86% · Lower 95% interval 33.65% |
| 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 51 · Denominator 51 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 51 |
| Discharge self-care score | 40.63% |
53.69%
13.1 pts worse
|
Numerator 13 · Denominator 32 |
| Discharge mobility score | 28.13% |
50.94%
22.8 pts worse
|
Numerator 9 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 3.92% |
2.29%
1.6 pts worse
|
Numerator 2 · Denominator 51 · Adjusted rate 2.74% |
| Healthcare-associated infections requiring hospitalization | 8.46% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 39 · Observed rate 15.38% · Lower 95% interval 5.25% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 108 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 34.38% |
56.45%
22.1 pts worse
|
Numerator 11 · Denominator 32 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 25% |
25.2%
0.2 pts worse
|
Numerator 8 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.6
0.7 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.8 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.6
0.1 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.7 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
89.9%
9.3 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 100.0% · Q3 98.9% · Q4 98.9% · 4Q avg 99.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
94.5%
4.5 pts better
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
3.6%
2.2 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 76.0% |
11.8%
64.2 pts worse
|
11.4%
64.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 75.6% · Q2 75.9% · Q3 74.1% · Q4 78.7% · 4Q avg 76.0% |
| Percentage of long-stay residents who lose too much weight | 9.3% |
6.2%
3.1 pts worse
|
5.4%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 15.0% · Q3 6.5% · Q4 8.6% · 4Q avg 9.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 40.0% |
32.2%
7.8 pts worse
|
19.6%
20.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.6% · Q2 34.9% · Q3 44.4% · Q4 40.0% · 4Q avg 40.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.7% |
18.1%
2.4 pts better
|
16.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 12.5% · Q3 23.8% · Q4 16.0% · 4Q avg 15.7% · 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 | 7.5% |
19.9%
12.4 pts better
|
16.3%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 15.0% · Q3 0.0% · Q4 0.0% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.2% |
15.3%
10.1 pts better
|
14.9%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 5.4% · Q3 5.5% · Q4 0.0% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.9%
0.6 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 0.0% · 4Q avg 0.3% · 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 | 25.5% |
20.2%
5.3 pts worse
|
19.8%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 29.5% · Q3 27.5% · Q4 23.3% · 4Q avg 25.5% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
5.4%
1 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 4.6% · Q3 5.3% · Q4 1.4% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.6% |
79.6%
3 pts better
|
81.7%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 83.3% · Q2 84.3% · Q3 82.0% · Q4 80.4% · 4Q avg 82.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.7% |
11.2%
6.5 pts better
|
12.0%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.7% · Observed 4.9% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.7% |
1.6%
3.1 pts worse
|
1.6%
3.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 2.3% · Q3 6.8% · Q4 4.9% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.7% |
79.8%
1.1 pts worse
|
79.7%
1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.7% |
22.2%
3.5 pts worse
|
23.9%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.7% · Observed 29.3% · Expected 27.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-11-05 · Fire 2019-11-05
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2018-11-07 · Fire 2018-11-07
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-07-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-24
D · Potential for more than minimal harm
2019-11-05
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2019-11-22
D · Potential for more than minimal harm
2018-11-07
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2018-11-30
D · Potential for more than minimal harm
2018-11-07
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2018-11-30
D · Potential for more than minimal harm
2018-11-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-11-30
D · Potential for more than minimal harm
2018-11-07
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2018-11-30
Inspection history
Recent health citations
F · Potential for more than minimal harm
2023-07-25
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 2023-08-09
F · Potential for more than minimal harm
2019-11-05
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 2019-11-22
D · Potential for more than minimal harm
2019-11-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-11-22
D · Potential for more than minimal harm
2019-11-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-11-22
E · Potential for more than minimal harm
2018-11-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-11-30
D · Potential for more than minimal harm
2018-11-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2018-11-30
D · Potential for more than minimal harm
2018-11-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-11-30
Penalties and ownership
What sits behind the stars
Ownership
Blisko, Michael
5% Or Greater Direct Ownership Interest · Individual
Gubin Enterprises Limited Partnership
5% Or Greater Direct Ownership Interest · Organization
Garland, Wesley
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
The Waters Of Johnson City, LLC
Johnson City, TN
2-star overall rating with 3-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Agape Rehabilitation & Nursing Center, A Waters Cm
Johnson City, TN
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Abundant Christian Living Community Rehabilitation
Johnson City, TN
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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