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

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

0.32

Registered nurse staffing · state 0.61 · national 0.68

LPN hours / resident day

1.32

Licensed practical nurse staffing · state 1.09 · national 0.87

Aide hours / resident day

1.59

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

1.64

RN + LPN hours · state 1.70 · national 1.54

Weekend hours

2.87

Weekend nurse staffing · state 3.34 · national 3.43

Weekend RN hours

0.22

Weekend registered nurse coverage · state 0.40 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.08 · national 0.07

Adjusted RN hours

0.25

CMS adjusted RN staffing hours

Adjusted total hours

2.50

CMS adjusted total nurse staffing hours

Case-mix index

1.77

Higher values indicate more complex resident acuity

RN turnover

60%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

51%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

13,226

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

7.34

Composite VBP score used to determine payment impact.

Payment multiplier

0.9807

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0.78

Baseline 20.19% · Performance 21.07% · Measure score 0.78 · Achievement 0.78 · Improvement 0

Healthcare-associated infections

0

Baseline 6.74% · Performance 8.92% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

2.16

Baseline 67.74% · Performance 56.34% · Measure score 2.16 · Achievement 1.80 · Improvement 2.16

Adjusted total nurse staffing

0

Baseline 2.49 hours · Performance 2.53 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.68%	10.72% 1 pts worse	No Different than the National Rate · Eligible stays 62 · Observed rate 14.52% · Lower 95% interval 7.98%
Discharge to community	57.42%	50.57% 6.9 pts better	No Different than the National Rate · Eligible stays 43 · Observed rate 53.49% · Lower 95% interval 43.87%
Medicare spending per beneficiary	1.35	1.02 0.3 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 47 · Denominator 47
Falls with major injury	2.13%	0.77% 1.4 pts worse	Numerator 1 · Denominator 47
Discharge self-care score	62.5%	53.69% 8.8 pts better	Numerator 20 · Denominator 32
Discharge mobility score	53.13%	50.94% 2.2 pts better	Numerator 17 · Denominator 32
Pressure ulcers or injuries, new or worsened	2.13%	2.29% 0.2 pts better	Numerator 1 · Denominator 47 · Adjusted rate 1.48%
Healthcare-associated infections requiring hospitalization	8.92%	7.12% 1.8 pts worse	No Different than the National Rate · Eligible stays 51 · Observed rate 13.73% · Lower 95% interval 4.42%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 71
Staff flu vaccination coverage	5.74%	42% 36.3 pts worse	Numerator 7 · Denominator 122
Discharge function score	56.25%	56.45% 0.2 pts worse	Numerator 18 · Denominator 32
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 28 · Denominator 28
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	35%	25.2% 9.8 pts better	Numerator 7 · Denominator 20

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 · Adjusted 1.6 · Observed 1.9 · Expected 2.3 · Used in QM five-star
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 · Adjusted 1.9 · Observed 1.9 · Expected 1.7 · Used in QM five-star
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 · Q1 98.4% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6%
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	4.6%	3.6% 1 pts worse	3.3% 1.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 6.0% · Q3 4.7% · Q4 3.1% · 4Q avg 4.6% · Used in QM five-star
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 · Q1 77.0% · Q2 79.7% · Q3 79.0% · Q4 68.3% · 4Q avg 76.1%
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 · Q1 10.5% · Q2 6.7% · Q3 5.0% · Q4 5.1% · 4Q avg 6.8%
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 29.3% · Q2 27.0% · Q3 29.5% · Q4 34.4% · 4Q avg 30.0%
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 · Q1 10.0% · Q2 7.3% · Q3 12.5% · Q4 6.0% · 4Q avg 8.9% · 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	6.1%	19.9% 13.8 pts better	16.3% 10.2 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 6.1% · Used in QM five-star
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 · Q1 5.4% · Q2 14.8% · Q3 3.4% · Q4 3.4% · 4Q avg 6.8% · 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	0.4%	1.9% 1.5 pts better	1.7% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
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 · Q1 20.3% · Q2 18.5% · Q3 15.8% · Q4 15.8% · 4Q avg 17.6%
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 · Q1 5.1% · Q2 4.1% · Q3 2.4% · Q4 3.7% · 4Q avg 3.8% · Used in QM five-star
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 · Q1 78.5% · Q2 91.3% · Q3 96.0% · Q4 90.4% · 4Q avg 89.4%
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 · Adjusted 12.5% · Observed 12.5% · Expected 11.2% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
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 · 4Q avg 93.2%
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 · Adjusted 23.1% · Observed 23.2% · Expected 23.9% · Used in QM five-star

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