THE WATERS OF CHEATHAM, LLC Inspection Report, Violations & Safety Grade (ASHLAND CITY, Tennessee)

2501 RIVER ROAD, ASHLAND CITY, Tennessee 37015

Phone: 6157924948

CMS Overall:2/5

Overview & Bed Count

Certified Beds

Avg Residents/Day

48.1

Ownership

For profit - Limited Liability company

Provider Type

Medicare and Medicaid

County

Cheatham

Sprinkler Systems

Yes

Special Focus

None

Abuse Citation

CMS Star Ratings

Overall2/5

Health2/5

Staffing1/5

Quality5/5

Nurse Staffing Check

Metric	This Facility	Tennessee Avg	Difference
RN Hours per Resident per Day	0.42	0.60	-0.17
Total Nurse Hours per Resident per Day	3.41	3.82	-0.41
CMS Staffing Rating	1/5	2.5/5	-
Nursing Staff Turnover	64.1%	48.6%	-

Health Citation History

24 health citations on record

Date	Category	Description	Severity
2026-03-26	Infection Control Deficiencies	Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.	F – Moderate Harm Potential
2026-03-26	Quality of Life and Care Deficiencies	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	E – Moderate Harm Potential
2026-03-26	Administration Deficiencies	Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.	E – Moderate Harm Potential
2026-03-26	Resident Rights Deficiencies	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.	D – Moderate Harm Potential
2026-03-26	Quality of Life and Care Deficiencies	Provide activities to meet all resident's needs.	D – Moderate Harm Potential
2026-03-26	Nursing and Physician Services Deficiencies	Post nurse staffing information every day.	D – Moderate Harm Potential
2022-04-27	Resident Rights Deficiencies	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	E – Moderate Harm Potential
2022-04-27	Resident Rights Deficiencies	Allow resident to participate in the development and implementation of his or her person-centered plan of care.	E – Moderate Harm Potential
2022-04-27	Pharmacy Service Deficiencies	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.	E – Moderate Harm Potential
2022-04-27	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2022-04-27	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	E – Moderate Harm Potential
2022-04-27	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Develop and implement policies and procedures to prevent abuse, neglect, and theft.	D – Moderate Harm Potential
2022-04-27	Resident Rights Deficiencies	Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.	D – Moderate Harm Potential
2022-04-27	Resident Assessment and Care Planning Deficiencies	Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted	D – Moderate Harm Potential
2022-04-27	Pharmacy Service Deficiencies	Ensure that residents are free from significant medication errors.	D – Moderate Harm Potential
2019-10-23	Resident Rights Deficiencies	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	E – Moderate Harm Potential
2019-10-23	Pharmacy Service Deficiencies	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.	E – Moderate Harm Potential
2019-10-23	Resident Assessment and Care Planning Deficiencies	Assess the resident when there is a significant change in condition	D – Moderate Harm Potential
2019-10-23	Resident Assessment and Care Planning Deficiencies	Ensure each resident receives an accurate assessment.	D – Moderate Harm Potential
2019-10-23	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2019-10-23	Quality of Life and Care Deficiencies	Provide activities to meet all resident's needs.	D – Moderate Harm Potential
2019-10-23	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	D – Moderate Harm Potential
2019-10-23	Resident Assessment and Care Planning Deficiencies	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	D – Moderate Harm Potential
2019-10-23	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	D – Moderate Harm Potential

Fire Safety Citation History

15 fire safety citations on record

Date	Category	Description	Severity
2026-03-26	Emergency Preparedness Deficiencies	Include a process for Emergency Preparedness collaboration.	D – Moderate Harm Potential
2026-03-26	Emergency Preparedness Deficiencies	Establish policies and procedures including evacuation.	D – Moderate Harm Potential
2026-03-26	Emergency Preparedness Deficiencies	Establish roles under a Waiver declared by secretary.	D – Moderate Harm Potential
2026-03-26	Emergency Preparedness Deficiencies	Provide a means of sharing information on occupancy/needs.	D – Moderate Harm Potential
2026-03-26	Emergency Preparedness Deficiencies	Conduct testing and exercise requirements.	D – Moderate Harm Potential
2026-03-26	Smoke Deficiencies	Provide properly protected cooking facilities.	D – Moderate Harm Potential
2026-03-26	Smoke Deficiencies	Have approved installation, maintenance and testing program for fire alarm systems.	D – Moderate Harm Potential
2026-03-26	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	D – Moderate Harm Potential
2022-04-27	Miscellaneous Deficiencies	Have simulated fire drills held at unexpected times.	E – Moderate Harm Potential
2019-10-23	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	E – Moderate Harm Potential
2019-10-23	Emergency Preparedness Deficiencies	Address subsistence needs for staff and patients.	D – Moderate Harm Potential
2019-10-23	Emergency Preparedness Deficiencies	Establish policies and procedures for volunteers.	D – Moderate Harm Potential
2019-10-23	Emergency Preparedness Deficiencies	Provide primary/alternate means for communication.	D – Moderate Harm Potential
2019-10-23	Smoke Deficiencies	Provide properly protected cooking facilities.	D – Moderate Harm Potential
2019-10-23	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	D – Moderate Harm Potential

Total Penalties & Fines

$2,117

Total Fine Amount (CMS)

Number of Fines

Total Penalties

Date	Type	Fine Amount	Payment Denial
2023-10-23	Fine	$2,117	-

Verified Helpline

Care & Coverage Review

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Health Insurance Helpline
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Verified Helpline

Care & Coverage Review

Researching facilities in ASHLAND CITY, Tennessee? Speak with a licensed specialist to review your Medicare or health insurance benefits at no cost.

📞 Call (866) 227-7595
Medicare & Benefits Review
(Ages 64.5+)📞 Call (866) 228-4856
Health Insurance Helpline
(Ages 26–64)

Free, confidential consultation. We may receive referral compensation.