Cycle 1
Health 2022-08-10 · Fire 2022-08-10
17 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Smyrna, TN
The Waters Of Smyrna, LLC
1-star overall rating with 1-star inspections with $104,124 in total fines with 17 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
202 Enon Springs Road East, Smyrna, TN
(615) 459-5600
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
91
Certified beds
Average residents
63
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Infinity Healthcare Consulting
Operator or chain grouping
Approved since
2011-03-24
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
0.40
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.12
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.55
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.24
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.25
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
0.34
CMS adjusted RN staffing hours
Adjusted total hours
3.00
CMS adjusted total nurse staffing hours
Case-mix index
1.62
Higher values indicate more complex resident acuity
RN turnover
90%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
84%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,718
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0.59
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0.12
Baseline 80.25% · Performance 76.83% · Measure score 0.12 · Achievement 0 · Improvement 0.12
Adjusted total nurse staffing
0
Baseline 2.35 hours · Performance 2.51 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.36% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 8% · Lower 95% interval 7.03% |
| Discharge to community | 41.19% |
50.57%
9.4 pts worse
|
No Different than the National Rate · Eligible stays 53 · Observed rate 35.85% · Lower 95% interval 30.48% |
| Medicare spending per beneficiary | 1.42 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 31 · Denominator 31 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 31 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 31 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 6.9% |
42%
35.1 pts worse
|
Numerator 8 · Denominator 116 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 4.55% |
25.2%
20.6 pts worse
|
Numerator 1 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.6
0.1 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.7 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.6
0.1 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · Expected 1.6 · 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 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.2% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.8% |
94.5%
2.3 pts better
|
95.5%
1.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.8% |
3.6%
1.2 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.3% · Q3 5.3% · Q4 9.1% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 56.7% |
11.8%
44.9 pts worse
|
11.4%
45.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 79.6% · Q2 76.8% · Q3 34.5% · Q4 34.0% · 4Q avg 56.7% |
| Percentage of long-stay residents who lose too much weight | 16.7% |
6.2%
10.5 pts worse
|
5.4%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 15.1% · Q3 19.2% · Q4 17.0% · 4Q avg 16.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.9% |
32.2%
12.3 pts better
|
19.6%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 18.2% · Q3 15.4% · Q4 22.9% · 4Q avg 19.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.4% |
18.1%
7.7 pts better
|
16.7%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 9.3% · Q3 14.0% · Q4 16.7% · 4Q avg 10.4% · 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 | 5.6% |
19.9%
14.3 pts better
|
16.3%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.7% |
15.3%
8.6 pts better
|
14.9%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 3.8% · Q3 12.0% · Q4 8.9% · 4Q avg 6.7% · 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 | 1.3% |
1.9%
0.6 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 3.7% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.9% |
20.2%
1.7 pts worse
|
19.8%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 30.0% · Q3 32.3% · Q4 17.0% · 4Q avg 21.9% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
5.4%
0.9 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 4.2% · Q3 5.6% · Q4 5.3% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
79.6%
18.7 pts better
|
81.7%
16.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 97.3% · Q3 98.9% · Q4 100.0% · 4Q avg 98.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.4% |
11.2%
8.2 pts worse
|
12.0%
7.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.4% · Observed 20.6% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.6%
0.3 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 1.6% · Q4 4.1% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.9% |
79.8%
5.9 pts worse
|
79.7%
5.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 73.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 46.2% |
22.2%
24 pts worse
|
23.9%
22.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 46.2% · Observed 52.9% · Expected 27.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-08-07 · Fire 2019-08-07
13 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2018-06-13 · Fire 2018-06-13
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-04-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-06
D · Potential for more than minimal harm
2022-08-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-08-29
D · Potential for more than minimal harm
2022-08-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-29
D · Potential for more than minimal harm
2022-08-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-29
D · Potential for more than minimal harm
2022-08-10
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-08-29
F · Potential for more than minimal harm
2019-08-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-09-21
D · Potential for more than minimal harm
2019-08-07
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-09-21
D · Potential for more than minimal harm
2019-08-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-09-21
D · Potential for more than minimal harm
2019-08-07
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2019-09-21
D · Potential for more than minimal harm
2018-06-13
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 2018-07-28
D · Potential for more than minimal harm
2018-06-13
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2018-07-28
D · Potential for more than minimal harm
2018-06-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2018-07-28
Inspection history
Recent health citations
K · Immediate jeopardy
2024-06-21
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 2024-06-24
K · Immediate jeopardy
2024-06-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-24
J · Immediate jeopardy
2024-06-21
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-06-24
F · Potential for more than minimal harm
2024-06-21
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 2024-07-09
F · Potential for more than minimal harm
2024-06-21
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 2024-07-09
F · Potential for more than minimal harm
2024-06-21
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 2024-07-08
E · Potential for more than minimal harm
2024-06-21
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 2024-07-09
D · Potential for more than minimal harm
2024-06-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-06-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-06-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-09
F · Potential for more than minimal harm
2023-08-15
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-09-07
E · Potential for more than minimal harm
2022-08-10
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-08-22
E · Potential for more than minimal harm
2022-08-10
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 2022-08-22
D · Potential for more than minimal harm
2022-08-10
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 2022-08-22
D · Potential for more than minimal harm
2022-08-10
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-08-22
D · Potential for more than minimal harm
2022-08-10
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-08-22
D · Potential for more than minimal harm
2022-08-10
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-08-22
D · Potential for more than minimal harm
2022-08-10
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 2022-08-22
D · Potential for more than minimal harm
2022-08-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-08-22
D · Potential for more than minimal harm
2022-08-10
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 2022-08-22
D · Potential for more than minimal harm
2022-08-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-08-22
D · Potential for more than minimal harm
2022-08-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-08-22
D · Potential for more than minimal harm
2022-08-10
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 2022-08-22
D · Potential for more than minimal harm
2022-08-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-08-22
D · Potential for more than minimal harm
2022-08-10
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2022-08-22
D · Potential for more than minimal harm
2022-08-10
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-08-22
D · Potential for more than minimal harm
2022-08-10
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-08-22
D · Potential for more than minimal harm
2022-08-10
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-08-22
D · Potential for more than minimal harm
2019-08-07
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2019-09-02
D · Potential for more than minimal harm
2019-08-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-09-02
D · Potential for more than minimal harm
2019-08-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-09-02
F · Potential for more than minimal harm
2018-06-13
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2018-07-28
D · Potential for more than minimal harm
2018-06-13
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2018-07-28
D · Potential for more than minimal harm
2018-06-13
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2018-07-28
D · Potential for more than minimal harm
2018-06-13
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2018-07-28
D · Potential for more than minimal harm
2018-06-13
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2018-07-28
Penalties and ownership
What sits behind the stars
$97,773
2024-06-21
Fine
Fine · fine $97,773
Fine
$0
2024-06-21
Payment Denial
Payment Denial · denial start 2024-06-27 · 12 days
12 day denial
$6,351
2023-04-17
Fine
Fine · fine $6,351
Fine
Ownership
Blisko, Michael
5% Or Greater Direct Ownership Interest · Individual
Gubin Enterprises Limited Partnership
5% Or Greater Direct Ownership Interest · Organization
Hall, Alan
W-2 Managing Employee · Individual
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