Shelbyville, TN

The Waters Of Shelbyville, LLC

3-star overall rating with 3-star inspections with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle

835 Union Street, Shelbyville, TN

(931) 680-2300

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

96

Certified beds

Average residents

72

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Infinity Healthcare Consulting

Operator or chain grouping

Approved since

1985-01-11

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.32

Registered nurse staffing

LPN hours / resident day

1.32

Licensed practical nurse staffing

Aide hours / resident day

1.59

Nurse aide staffing

Weekend hours

2.87

Weekend nurse staffing

RN turnover

60%

Annual RN turnover

Total nurse turnover

51%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.6	1.6 About the same	1.9 0.3 pts better	Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days	1.9	1.6 0.3 pts worse	1.8 0.1 pts worse	Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.6%	89.9% 9.7 pts better	93.4% 6.2 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	4.6%	3.6% 1 pts worse	3.3% 1.3 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	76.1%	11.8% 64.3 pts worse	11.4% 64.7 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	6.8%	6.2% 0.6 pts worse	5.4% 1.4 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	8.9%	18.1% 9.2 pts better	16.7% 7.8 pts better	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	6.1%	19.9% 13.8 pts better	16.3% 10.2 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	6.8%	15.3% 8.5 pts better	14.9% 8.1 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	0.4%	1.9% 1.5 pts better	1.7% 1.3 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	17.6%	20.2% 2.6 pts better	19.8% 2.2 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	3.8%	5.4% 1.6 pts better	5.1% 1.3 pts better	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	89.4%	79.6% 9.8 pts better	81.7% 7.7 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	12.5%	11.2% 1.3 pts worse	12.0% 0.5 pts worse	Short Stay · 20240701-20250630
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
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	93.2%	79.8% 13.4 pts better	79.7% 13.5 pts better	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	23.1%	22.2% 0.9 pts worse	23.9% 0.8 pts better	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2019-11-06 · Fire 2019-11-06

4 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

7 fire-safety deficiencies

Top issue: Egress (3 deficiencies)

Cycle 2 Health 2018-12-05 · Fire 2018-12-05

3 health deficiencies

Top issue: Pharmacy Service (1 deficiency)

4 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2017-12-06 · Fire 2017-12-06

8 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2019-11-06

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2019-12-18

E · Potential for more than minimal harm 2019-11-06

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2019-12-18

D · Potential for more than minimal harm 2019-11-06

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2019-12-18

D · Potential for more than minimal harm 2019-11-06

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2019-12-18

D · Potential for more than minimal harm 2019-11-06

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2019-12-18

D · Potential for more than minimal harm 2019-11-06

K343 · Smoke Deficiencies

Fire Safety

Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

Corrected 2019-12-18

D · Potential for more than minimal harm 2019-11-06

K919 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the use of electrical equipment.

Corrected 2019-12-18

F · Potential for more than minimal harm 2018-12-05

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2019-01-15

F · Potential for more than minimal harm 2018-12-05

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-01-15

F · Potential for more than minimal harm 2018-12-05

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2019-01-15

D · Potential for more than minimal harm 2018-12-05

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2019-01-15

D · Potential for more than minimal harm 2017-12-06

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2018-01-03

D · Potential for more than minimal harm 2017-12-06

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 2018-01-03

D · Potential for more than minimal harm 2017-12-06

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2018-01-03

D · Potential for more than minimal harm 2017-12-06

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2018-01-03

D · Potential for more than minimal harm 2017-12-06

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2018-01-03

D · Potential for more than minimal harm 2017-12-06

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2018-01-03

D · Potential for more than minimal harm 2017-12-06

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2018-01-03

D · Potential for more than minimal harm 2017-12-06

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2018-01-03

D · Potential for more than minimal harm 2017-12-06

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2018-01-03

Inspection history

Recent health citations

D · Potential for more than minimal harm 2023-11-29

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-01-11

D · Potential for more than minimal harm 2023-11-29

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-01-11

J · Immediate jeopardy 2019-11-06

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 2019-08-20

E · Potential for more than minimal harm 2019-11-06

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 2019-12-09

D · Potential for more than minimal harm 2019-11-06

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2019-12-09

D · Potential for more than minimal harm 2019-11-06

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2019-12-09

D · Potential for more than minimal harm 2018-12-05

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2019-01-15

D · Potential for more than minimal harm 2018-12-05

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2019-01-15

D · Potential for more than minimal harm 2018-12-05

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2019-01-15

G · Actual harm 2017-12-06

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 2018-01-03

F · Potential for more than minimal harm 2017-12-06

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2018-01-03

E · Potential for more than minimal harm 2017-12-06

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2018-01-03

D · Potential for more than minimal harm 2017-12-06

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2018-01-03

D · Potential for more than minimal harm 2017-12-06

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2018-01-03

D · Potential for more than minimal harm 2017-12-06

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2018-01-03

Penalties and ownership