Cycle 1
Health 2025-04-08 · Fire 2025-04-08
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Roan Mountain, TN
The Waters Of Roan Highlands,llc
5-star overall rating with 5-star inspections with 4 fire-safety deficiencies in the latest cycle
146 Buck Creek Road, Roan Mountain, TN
(423) 772-0161
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
80
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Infinity Healthcare Consulting
Operator or chain grouping
Approved since
1997-05-20
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
0.43
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
1.86
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.22
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
2.78
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.30
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
0.34
CMS adjusted RN staffing hours
Adjusted total hours
2.54
CMS adjusted total nurse staffing hours
Case-mix index
1.73
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,020
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.40
Composite VBP score used to determine payment impact.
Payment multiplier
0.9998
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
5.33
Baseline 6.52% · Performance 6.24% · Measure score 5.33 · Achievement 5.33 · Improvement 1.31
Total nurse turnover
8.59
Baseline 30.91% · Performance 28.57% · Measure score 8.59 · Achievement 8.59 · Improvement 3.36
Adjusted total nurse staffing
0
Baseline 2.52 hours · Performance 2.65 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.07% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 13.89% · Lower 95% interval 6.55% |
| Discharge to community | 59.28% |
50.57%
8.7 pts better
|
No Different than the National Rate · Eligible stays 26 · Observed rate 61.54% · Lower 95% interval 43.81% |
| Medicare spending per beneficiary | 1.23 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 93.1% |
95.27%
2.2 pts worse
|
Numerator 27 · Denominator 29 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 29 |
| Discharge self-care score | 35.71% |
53.69%
18 pts worse
|
Numerator 10 · Denominator 28 |
| Discharge mobility score | 28.57% |
50.94%
22.4 pts worse
|
Numerator 8 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 29 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.24% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 27 · Observed rate 0% · Lower 95% interval 2.59% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 94 |
| Staff flu vaccination coverage | 13.01% |
42%
29 pts worse
|
Numerator 16 · Denominator 123 |
| Discharge function score | 35.71% |
56.45%
20.7 pts worse
|
Numerator 10 · Denominator 28 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 20% |
25.2%
5.2 pts worse
|
Numerator 4 · Denominator 20 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.6
0.7 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.6 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
1.6
1.3 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.2 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.9%
10.1 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 4.2% |
3.6%
0.6 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 5.6% · Q3 2.8% · Q4 4.1% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 64.0% |
11.8%
52.2 pts worse
|
11.4%
52.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 60.3% · Q2 69.6% · Q3 67.2% · Q4 58.8% · 4Q avg 64.0% |
| Percentage of long-stay residents who lose too much weight | 1.3% |
6.2%
4.9 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.1% · Q4 0.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 58.1% |
32.2%
25.9 pts worse
|
19.6%
38.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 55.4% · Q2 56.9% · Q3 60.0% · Q4 60.0% · 4Q avg 58.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.1% |
18.1%
3 pts worse
|
16.7%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 21.4% · Q3 20.4% · Q4 25.0% · 4Q avg 21.1% · 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 | 11.3% |
19.9%
8.6 pts better
|
16.3%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 13.1% · Q4 0.0% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.7% |
15.3%
7.6 pts better
|
14.9%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 12.1% · Q3 0.0% · Q4 0.0% · 4Q avg 7.7% · 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 | 28.1% |
20.2%
7.9 pts worse
|
19.8%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.3% · Q2 28.1% · Q3 28.4% · Q4 33.2% · 4Q avg 28.1% |
| Percentage of long-stay residents with pressure ulcers | 0.8% |
5.4%
4.6 pts better
|
5.1%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.8% · Q3 1.7% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
79.6%
20.4 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.2% |
11.2%
6 pts better
|
12.0%
6.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.2% · Observed 4.8% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.6%
1.6 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.2% |
79.8%
17.4 pts better
|
79.7%
17.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 0.0% |
22.2%
22.2 pts better
|
23.9%
23.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 20.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-03-16 · Fire 2022-03-16
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 2019-05-21 · Fire 2019-05-21
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-23
F · Potential for more than minimal harm
2025-04-08
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-04-08
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-04-25
D · Potential for more than minimal harm
2019-05-21
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-06-05
Inspection history
Recent health citations
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
A&F Realty LLC
5% Or Greater Direct Ownership Interest · Organization
Cable, Erika
W-2 Managing Employee · Individual
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