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
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
0.35
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.10
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
1.78
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.23
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
2.85
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
0.02
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.30
CMS adjusted RN staffing hours
Adjusted total hours
2.74
CMS adjusted total nurse staffing hours
Case-mix index
1.62
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,579
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.88
Composite VBP score used to determine payment impact.
Payment multiplier
0.9823
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.32% · Performance 21.44% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.78
Baseline 7.22% · Performance 6.40% · Measure score 4.78 · Achievement 4.78 · Improvement 3.17
Total nurse turnover
3.17
Baseline 65.28% · Performance 50.72% · Measure score 3.17 · Achievement 3.17 · Improvement 3.1
Adjusted total nurse staffing
0
Baseline 2.48 hours · Performance 2.64 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.45% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 73 · Observed rate 13.7% · Lower 95% interval 7.58% |
| Discharge to community | 45.18% |
50.57%
5.4 pts worse
|
No Different than the National Rate · Eligible stays 63 · Observed rate 34.92% · Lower 95% interval 34.13% |
| Medicare spending per beneficiary | 1.31 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 98.46% |
95.27%
3.2 pts better
|
Numerator 64 · Denominator 65 |
| Falls with major injury | 3.08% |
0.77%
2.3 pts worse
|
Numerator 2 · Denominator 65 |
| Discharge self-care score | 47.37% |
53.69%
6.3 pts worse
|
Numerator 18 · Denominator 38 |
| Discharge mobility score | 52.63% |
50.94%
1.7 pts better
|
Numerator 20 · Denominator 38 |
| Pressure ulcers or injuries, new or worsened | 1.56% |
2.29%
0.7 pts better
|
Numerator 1 · Denominator 64 · Adjusted rate 1.17% |
| Healthcare-associated infections requiring hospitalization | 6.41% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 4% · Lower 95% interval 3.12% |
| Staff COVID-19 vaccination coverage | 17.02% |
8.2%
8.8 pts better
|
Numerator 16 · Denominator 94 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 65.79% |
56.45%
9.3 pts better
|
Numerator 25 · Denominator 38 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 39 · Denominator 39 |
| 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 | 6.25% |
25.2%
18.9 pts worse
|
Numerator 2 · Denominator 32 |
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 · Q1 98.5% · Q2 100.0% · Q3 98.7% · Q4 97.3% · 4Q avg 98.6% |
| 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 · 4Q avg 100.0% |
| 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 · Q1 4.5% · Q2 5.3% · Q3 6.4% · Q4 4.1% · 4Q avg 5.1% · Used in QM five-star |
| 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 · Q1 41.9% · Q2 50.0% · Q3 52.1% · Q4 43.7% · 4Q avg 47.1% |
| 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 · Q1 4.9% · Q2 11.4% · Q3 11.9% · Q4 11.4% · 4Q avg 10.1% |
| 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 · Q1 26.2% · Q2 30.0% · Q3 31.9% · Q4 31.4% · 4Q avg 30.0% |
| 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 · Q1 22.0% · Q2 31.1% · Q3 22.2% · Q4 23.2% · 4Q avg 24.5% · 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 | 18.4% |
19.9%
1.5 pts better
|
16.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.4% · Used in QM five-star |
| 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 · Q1 5.3% · Q2 6.2% · Q3 4.8% · Q4 9.2% · 4Q avg 6.5% · 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 | 1.7% |
1.9%
0.2 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 1.3% · Q4 4.1% · 4Q avg 1.7% · Used in QM five-star |
| 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 · Q1 23.5% · Q2 26.0% · Q3 21.3% · Q4 21.7% · 4Q avg 23.1% |
| 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 · Q1 1.4% · Q2 2.4% · Q3 5.4% · Q4 1.1% · 4Q avg 2.6% · Used in QM five-star |
| 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 · Q1 94.3% · Q2 91.7% · Q3 82.3% · Q4 86.2% · 4Q avg 89.2% |
| 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 · Adjusted 5.8% · Observed 7.1% · Expected 13.7% · Used in QM five-star |
| 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 · Q1 3.2% · Q2 5.4% · Q3 4.1% · Q4 0.0% · 4Q avg 3.2% · Used in QM five-star |
| 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 · 4Q avg 87.0% |
| 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 · Adjusted 32.5% · Observed 39.3% · Expected 28.9% · Used in QM five-star |
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
Nearby options
Other facilities in reach
#1
Gallatin Center For Rehabilitation And Healing
Gallatin, TN
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Nhc Place Sumner
Gallatin, TN
5-star overall rating with 4-star inspections with 2 recent health deficiencies
#3
Signature Health Of Portland Rehab & Wellness Cent
Portland, TN
1-star overall rating with 1-star inspections with abuse icon flag with $107,228 in total fines with 9 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
Jump out