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
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
0.33
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.36
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.79
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.69
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.55
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
0.02
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.26
CMS adjusted RN staffing hours
Adjusted total hours
2.99
CMS adjusted total nurse staffing hours
Case-mix index
1.73
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,487
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.12
Baseline 19.99% · Performance 19.52% · Measure score 4.12 · Achievement 4.12 · Improvement 1.08
Healthcare-associated infections
0.44
Baseline 8.60% · Performance 8.26% · Measure score 0.44 · Achievement 0 · Improvement 0.44
Total nurse turnover
0
Baseline 62.82% · Performance 64.13% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.24
Baseline 2.59 hours · Performance 2.83 hours · Measure score 0.24 · Achievement 0 · Improvement 0.24
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.22% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 8.33% · Lower 95% interval 6.63% |
| Discharge to community | 53.23% |
50.57%
2.7 pts better
|
No Different than the National Rate · Eligible stays 36 · Observed rate 38.89% · Lower 95% interval 38.71% |
| Medicare spending per beneficiary | 1.66 |
1.02
0.6 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 30 · Denominator 30 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 30 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · 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 30 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.26% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 34 · Observed rate 14.71% · Lower 95% interval 4.65% |
| Staff COVID-19 vaccination coverage | 3.64% |
8.2%
4.6 pts worse
|
Numerator 4 · Denominator 110 |
| Staff flu vaccination coverage | 5.71% |
42%
36.3 pts worse
|
Numerator 6 · Denominator 105 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 5% |
25.2%
20.2 pts worse
|
Numerator 1 · Denominator 20 |
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 · Adjusted 2.9 · Observed 2.4 · Expected 1.6 · Used in QM five-star |
| 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 · Adjusted 1.5 · Observed 1.3 · Expected 1.5 · Used in QM five-star |
| 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 · Q1 71.2% · Q2 52.2% · Q3 48.4% · Q4 72.3% · 4Q avg 61.1% |
| 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 · 4Q avg 91.7% |
| 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 · Q1 4.5% · Q2 6.0% · Q3 4.7% · Q4 4.6% · 4Q avg 5.0% · Used in QM five-star |
| 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 · Q1 72.6% · Q2 73.0% · Q3 77.8% · Q4 78.0% · 4Q avg 75.2% |
| 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 · Q1 6.8% · Q2 18.3% · Q3 15.8% · Q4 8.8% · 4Q avg 12.4% |
| 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 · Q1 44.1% · Q2 47.5% · Q3 50.8% · Q4 54.4% · 4Q avg 49.2% |
| 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 · Q1 14.9% · Q2 16.3% · Q3 18.6% · Q4 11.4% · 4Q avg 15.3% · 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 | 11.2% |
19.9%
8.7 pts better
|
16.3%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q2 10.7% · Q3 4.8% · 4Q avg 11.2% · Used in QM five-star |
| 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 · Q1 7.8% · Q2 3.8% · Q3 1.9% · Q4 3.8% · 4Q avg 4.3% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.1% · 4Q avg 0.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 4.8% · Q4 3.1% · 4Q avg 1.9% · Used in QM five-star |
| 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 · Q1 32.6% · Q2 31.1% · Q3 20.6% · Q4 31.2% · 4Q avg 29.0% |
| 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 · Q1 7.5% · Q2 11.7% · Q3 6.5% · Q4 8.7% · 4Q avg 8.6% · Used in QM five-star |
| 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 · Q1 75.4% · Q2 75.7% · Q3 80.2% · Q4 76.0% · 4Q avg 77.0% |
| 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 · Adjusted 17.1% · Observed 20.0% · Expected 13.0% · 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 | 78.9% |
79.8%
0.9 pts worse
|
79.7%
0.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.9% |
| 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 · Adjusted 21.2% · Observed 23.3% · Expected 26.2% · Used in QM five-star |
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
Nearby options
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#2
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#3
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