Cycle 1
Health 2019-12-18 · Fire 2019-12-18
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Gallatin, TN
The Waters Of Gallatin, LLC
3-star overall rating with 4-star inspections with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
555 East Bledsoe Street, Gallatin, TN
(615) 452-7132
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
124
Certified beds
Average residents
87
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Infinity Healthcare Consulting
Operator or chain grouping
Approved since
1978-05-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.35
Registered nurse staffing
LPN hours / resident day
1.10
Licensed practical nurse staffing
Aide hours / resident day
1.78
Nurse aide staffing
Weekend hours
2.85
Weekend nurse staffing
RN turnover
67%
Annual RN turnover
Total nurse turnover
50%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
89.9%
8.7 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.5%
5.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
3.6%
1.5 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 47.1% |
11.8%
35.3 pts worse
|
11.4%
35.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 10.1% |
6.2%
3.9 pts worse
|
5.4%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.0% |
32.2%
2.2 pts better
|
19.6%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 24.5% |
18.1%
6.4 pts worse
|
16.7%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.4% |
19.9%
1.5 pts better
|
16.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.5% |
15.3%
8.8 pts better
|
14.9%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.9%
0.2 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.1% |
20.2%
2.9 pts worse
|
19.8%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
5.4%
2.8 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.2% |
79.6%
9.6 pts better
|
81.7%
7.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.8% |
11.2%
5.4 pts better
|
12.0%
6.2 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.2% |
1.6%
1.6 pts worse
|
1.6%
1.6 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.0% |
79.8%
7.2 pts better
|
79.7%
7.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.5% |
22.2%
10.3 pts worse
|
23.9%
8.6 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-01-09 · Fire 2019-01-09
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2017-10-11 · Fire 2017-10-11
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2019-12-18
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2020-01-30
D · Potential for more than minimal harm
2019-12-18
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2020-01-30
D · Potential for more than minimal harm
2019-12-18
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2020-01-30
D · Potential for more than minimal harm
2019-12-18
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2020-01-30
D · Potential for more than minimal harm
2019-12-18
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2020-01-30
D · Potential for more than minimal harm
2019-12-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-01-30
D · Potential for more than minimal harm
2019-01-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-01-21
D · Potential for more than minimal harm
2019-01-09
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-01-18
D · Potential for more than minimal harm
2017-10-11
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2017-10-30
D · Potential for more than minimal harm
2017-10-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2017-10-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-02-19
D · Potential for more than minimal harm
2025-01-17
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 2025-02-19
D · Potential for more than minimal harm
2025-01-17
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-02-19
D · Potential for more than minimal harm
2023-03-22
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 2023-04-14
D · Potential for more than minimal harm
2023-03-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-03-22
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-04-14
D · Potential for more than minimal harm
2019-12-18
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 2020-01-31
D · Potential for more than minimal harm
2019-12-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-01-31
D · Potential for more than minimal harm
2019-01-09
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2019-01-23
D · Potential for more than minimal harm
2017-10-11
F223 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all abuse, physical punishment, and involuntary separation from others.
Corrected 2017-10-25
D · Potential for more than minimal harm
2017-10-11
F225 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
Corrected 2017-10-25
D · Potential for more than minimal harm
2017-10-11
F278 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment by a qualified health professional.
Corrected 2017-10-24
D · Potential for more than minimal harm
2017-10-11
F516 · Administration Deficiencies
Health
Keep clinical record information safe.
Corrected 2017-10-25
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
Willmore, Robin
W-2 Managing Employee · Individual
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