Springfield, TN

The Waters Of Springfield LLC

4-star overall rating with 3-star inspections with $9,422 in total fines with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

704 5th Avenue East, Springfield, TN

(615) 384-7977

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 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

66

Certified beds

Average residents

38

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Infinity Healthcare Consulting

Operator or chain grouping

Approved since

2005-10-07

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

0.96

Registered nurse staffing · state 0.61 · national 0.68

LPN hours / resident day

0.82

Licensed practical nurse staffing · state 1.09 · national 0.87

Aide hours / resident day

1.68

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

3.46

All reported nurse hours · state 3.85 · national 3.89

Licensed hours

1.78

RN + LPN hours · state 1.70 · national 1.54

Weekend hours

3.07

Weekend nurse staffing · state 3.34 · national 3.43

Weekend RN hours

0.72

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

0.77

CMS adjusted RN staffing hours

Adjusted total hours

2.78

CMS adjusted total nurse staffing hours

Case-mix index

1.70

Higher values indicate more complex resident acuity

RN turnover

44%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

62%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

13,726

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

Performance score

0

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

Baseline 63.46% · Performance 62.74% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

0

Baseline 3.21 hours · Performance 2.68 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.43%	10.72% 0.7 pts worse	No Different than the National Rate · Eligible stays 38 · Observed rate 15.79% · Lower 95% interval 7.85%
Discharge to community	48%	50.57% 2.6 pts worse	No Different than the National Rate · Eligible stays 31 · Observed rate 41.94% · Lower 95% interval 36.09%
Medicare spending per beneficiary	1.14	1.02 0.1 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 20 · Denominator 20
Falls with major injury	10%	0.77% 9.2 pts worse	Numerator 2 · Denominator 20
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	15%	2.29% 12.7 pts worse	Numerator 3 · Denominator 20 · Adjusted rate 12.47%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	16.18%	8.2% 8 pts better	Numerator 11 · Denominator 68
Staff flu vaccination coverage	30.99%	42% 11 pts worse	Numerator 22 · Denominator 71
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	88.4%	89.9% 1.5 pts worse	93.4% 5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 88.6% · Q2 96.9% · Q3 87.5% · Q4 80.0% · 4Q avg 88.4%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	94.7%	94.5% 0.2 pts better	95.5% 0.8 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 94.7%
Percentage of long-stay residents experiencing one or more falls with major injury	0.8%	3.6% 2.8 pts better	3.3% 2.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	36.1%	11.8% 24.3 pts worse	11.4% 24.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 0.0% · Q3 56.7% · Q4 72.4% · 4Q avg 36.1%
Percentage of long-stay residents who lose too much weight	9.1%	6.2% 2.9 pts worse	5.4% 3.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 10.7% · Q3 3.4% · Q4 20.0% · 4Q avg 9.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	36.9%	32.2% 4.7 pts worse	19.6% 17.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 37.9% · Q2 39.3% · Q3 37.9% · Q4 32.0% · 4Q avg 36.9%
Percentage of long-stay residents who received an antipsychotic medication	16.9%	18.1% 1.2 pts better	16.7% 0.2 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 16.9% · 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	0.0%	19.9% 19.9 pts better	16.3% 16.3 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	0.0%	15.3% 15.3 pts better	14.9% 14.9 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 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	1.6%	1.9% 0.3 pts better	1.7% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.1% · Q4 3.3% · 4Q avg 1.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	20.4%	20.2% 0.2 pts worse	19.8% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.2% · Q2 25.5% · Q3 17.9% · Q4 7.6% · 4Q avg 20.4%
Percentage of long-stay residents with pressure ulcers	5.0%	5.4% 0.4 pts better	5.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 5.4% · Q3 5.5% · Q4 4.6% · 4Q avg 5.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	50.4%	79.6% 29.2 pts worse	81.7% 31.3 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 69.7% · Q2 54.7% · Q3 40.3% · Q4 35.8% · 4Q avg 50.4%
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 3.3% · Q2 2.9% · Q3 3.4% · Q4 3.2% · 4Q avg 3.2% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	45.8%	79.8% 34 pts worse	79.7% 33.9 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 45.8%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-05-20 · Fire 2025-05-20

4 health deficiencies

Top issue: Infection Control (1 deficiency)

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2024-07-25 · Fire 2024-07-25

5 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

9 fire-safety deficiencies

Top issue: Egress (3 deficiencies)

Cycle 3 Health 2021-07-08 · Fire 2021-07-08

10 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

4 fire-safety deficiencies

Top issue: Emergency Preparedness (2 deficiencies)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-05-20

E31 · Emergency Preparedness Deficiencies

Fire Safety

Provide emergency officials' contact information.

Corrected 2025-06-18

D · Potential for more than minimal harm 2025-05-20

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-06-18

D · Potential for more than minimal harm 2025-05-20

K232 · Egress Deficiencies

Fire Safety

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Corrected 2025-06-18

D · Potential for more than minimal harm 2025-05-20

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-06-18

D · Potential for more than minimal harm 2025-05-20

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-06-18

D · Potential for more than minimal harm 2025-05-20

K374 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-06-18

F · Potential for more than minimal harm 2024-07-25

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-09-23

D · Potential for more than minimal harm 2024-07-25

E30 · Emergency Preparedness Deficiencies

Fire Safety

List the names and contact information of those in the facility.

Corrected 2024-09-24

D · Potential for more than minimal harm 2024-07-25

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2024-09-24

D · Potential for more than minimal harm 2024-07-25

K200 · Egress Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2024-09-23

D · Potential for more than minimal harm 2024-07-25

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 2024-09-23

D · Potential for more than minimal harm 2024-07-25

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2024-09-23

D · Potential for more than minimal harm 2024-07-25

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-09-23

D · Potential for more than minimal harm 2024-07-25

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-09-23

D · Potential for more than minimal harm 2024-07-25

K761 · Miscellaneous Deficiencies

Fire Safety

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

Corrected 2024-09-23

E · Potential for more than minimal harm 2021-07-08

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2021-08-20

E · Potential for more than minimal harm 2021-07-08

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2021-08-20

D · Potential for more than minimal harm 2021-07-08

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2021-08-20

D · Potential for more than minimal harm 2021-07-08

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2021-08-20

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-05-20

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 2025-07-14

D · Potential for more than minimal harm 2025-05-20

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2025-07-14

D · Potential for more than minimal harm 2025-05-20

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 2025-07-14

D · Potential for more than minimal harm 2025-05-20

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-07-14

F · Potential for more than minimal harm 2024-07-25

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 2024-08-24

E · Potential for more than minimal harm 2024-07-25

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 2024-03-18

D · Potential for more than minimal harm 2024-07-25

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2024-08-24

D · Potential for more than minimal harm 2024-07-25

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 2024-08-24

D · Potential for more than minimal harm 2024-07-25

F685 · Quality of Life and Care Deficiencies

Health

Assist a resident in gaining access to vision and hearing services.

Corrected 2024-08-24

J · Immediate jeopardy 2023-10-19

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 2022-08-07

D · Potential for more than minimal harm 2023-10-19

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2023-11-29

D · Potential for more than minimal harm 2023-10-19

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 2023-11-29

D · Potential for more than minimal harm 2023-10-19

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2023-11-29

D · Potential for more than minimal harm 2023-10-19

F865 · Administration Deficiencies

Health

Have a plan that describes the process for conducting QAPI and QAA activities.

Corrected 2023-11-29

D · Potential for more than minimal harm 2023-10-19

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-11-29

D · Potential for more than minimal harm 2021-07-08

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 2021-08-10

D · Potential for more than minimal harm 2021-07-08

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 2021-08-10

D · Potential for more than minimal harm 2021-07-08

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 2021-08-10

D · Potential for more than minimal harm 2021-07-08

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2021-08-10

Penalties and ownership

What sits behind the stars

$9,422 2023-10-19

Fine

Fine · fine $9,422

Fine

Ownership

Blisko, Michael

5% Or Greater Direct Ownership Interest · Individual

40% 33 facilities 2016-08-01

Gubin Enterprises Limited Partnership

5% Or Greater Direct Ownership Interest · Organization

40% 31 facilities 2016-08-01

A&F Realty LLC

5% Or Greater Direct Ownership Interest · Organization

20% 18 facilities 2016-08-01

Welsh, Benton

W-2 Managing Employee · Individual

0% 2 facilities 2020-08-05

Nearby options

Other facilities in reach

#1

Nhc Healthcare, Springfield

Springfield, TN

2-star overall rating with 1-star inspections with abuse icon flag with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

Overall: 2 / 5
Health: 1 / 5
Staffing: 2 / 5
Fines: $0

#2