Cycle 1
Health 2023-07-12 · Fire 2023-07-12
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
19 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Winchester, TN
The Waters Of Winchester, LLC
4-star overall rating with 5-star inspections with $19,325 in total fines with 1 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
1360 Bypass Road, Winchester, TN
(931) 967-7082
Overall
4 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
132
Certified beds
Average residents
75
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Infinity Healthcare Consulting
Operator or chain grouping
Approved since
1981-06-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.33
Registered nurse staffing
LPN hours / resident day
1.36
Licensed practical nurse staffing
Aide hours / resident day
2.10
Nurse aide staffing
Weekend hours
3.55
Weekend nurse staffing
RN turnover
75%
Annual RN turnover
Total nurse turnover
41%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
1.6
1.3 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.6
0.1 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 61.1% |
89.9%
28.8 pts worse
|
93.4%
32.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.7% |
94.5%
2.8 pts worse
|
95.5%
3.8 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.6%
1.4 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 75.2% |
11.8%
63.4 pts worse
|
11.4%
63.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 12.4% |
6.2%
6.2 pts worse
|
5.4%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 49.2% |
32.2%
17 pts worse
|
19.6%
29.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 15.3% |
18.1%
2.8 pts better
|
16.7%
1.4 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 | 11.2% |
19.9%
8.7 pts better
|
16.3%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.3% |
15.3%
11 pts better
|
14.9%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.9%
0.4 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
1.9%
About the same
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.0% |
20.2%
8.8 pts worse
|
19.8%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 8.6% |
5.4%
3.2 pts worse
|
5.1%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.0% |
79.6%
2.6 pts worse
|
81.7%
4.7 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.1% |
11.2%
5.9 pts worse
|
12.0%
5.1 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 | 78.9% |
79.8%
0.9 pts worse
|
79.7%
0.8 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.2% |
22.2%
1 pts better
|
23.9%
2.7 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-23 · Fire 2019-10-23
0 health deficiencies
No concentrated health issue counts in this cycle.
7 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2018-09-06 · Fire 2018-09-06
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-07-12
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-08-26
D · Potential for more than minimal harm
2023-07-12
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2023-08-26
D · Potential for more than minimal harm
2023-07-12
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-08-26
D · Potential for more than minimal harm
2023-07-12
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-08-26
D · Potential for more than minimal harm
2023-07-12
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-08-26
D · Potential for more than minimal harm
2023-07-12
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 2023-08-26
D · Potential for more than minimal harm
2023-07-12
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-08-26
D · Potential for more than minimal harm
2023-07-12
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-08-26
D · Potential for more than minimal harm
2023-07-12
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-08-26
D · Potential for more than minimal harm
2023-07-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-26
D · Potential for more than minimal harm
2023-07-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-26
D · Potential for more than minimal harm
2023-07-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-26
D · Potential for more than minimal harm
2023-07-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-08-26
D · Potential for more than minimal harm
2023-07-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-26
D · Potential for more than minimal harm
2023-07-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-26
D · Potential for more than minimal harm
2023-07-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-26
D · Potential for more than minimal harm
2023-07-12
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-08-26
D · Potential for more than minimal harm
2023-07-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-26
D · Potential for more than minimal harm
2023-07-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-26
D · Potential for more than minimal harm
2019-10-23
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-12-03
D · Potential for more than minimal harm
2019-10-23
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 2019-12-03
D · Potential for more than minimal harm
2019-10-23
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2019-12-03
D · Potential for more than minimal harm
2019-10-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-12-03
D · Potential for more than minimal harm
2019-10-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-12-03
D · Potential for more than minimal harm
2019-10-23
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 2019-12-03
D · Potential for more than minimal harm
2019-10-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-12-03
D · Potential for more than minimal harm
2018-09-06
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 2018-10-12
D · Potential for more than minimal harm
2018-09-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-10-12
D · Potential for more than minimal harm
2018-09-06
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2018-10-12
C · Minimal harm
2018-09-06
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2018-10-12
C · Minimal harm
2018-09-06
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2018-10-12
C · Minimal harm
2018-09-06
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2018-10-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-07-12
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2023-08-07
D · Potential for more than minimal harm
2018-09-06
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 2018-10-12
D · Potential for more than minimal harm
2018-09-06
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2018-10-12
D · Potential for more than minimal harm
2018-09-06
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 2018-10-12
Penalties and ownership
What sits behind the stars
$5,806
2023-07-12
Fine
Fine · fine $5,806
Fine
$6,757
2023-07-12
Fine
Fine · fine $6,757
Fine
$6,762
2023-07-12
Fine
Fine · fine $6,762
Fine
Ownership
Blisko, Michael
5% Or Greater Direct Ownership Interest · Individual
Gubin Enterprises Limited Partnership
5% Or Greater Direct Ownership Interest · Organization
Davis, John
W-2 Managing Employee · Individual
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#2
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3-star overall rating with 4-star inspections with 3 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
#3
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2-star overall rating with 2-star inspections with $39,507 in total fines with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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