B-
74/100THE WATERS OF SHELBYVILLE, LLC Inspection Report, Violations & Safety Grade (SHELBYVILLE, Tennessee)
835 UNION STREET, SHELBYVILLE, Tennessee 37160
Phone: 9316802300
CMS Overall:4/5
Overview & Bed Count
Certified Beds
96
Avg Residents/Day
71.4
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Bedford
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall4/5
Health4/5
Staffing1/5
Quality5/5
Nurse Staffing Check
| Metric | This Facility | Tennessee Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.33 | 0.60 | -0.27 |
| Total Nurse Hours per Resident per Day | 3.15 | 3.82 | -0.67 |
| CMS Staffing Rating | 1/5 | 2.5/5 | - |
| Nursing Staff Turnover | 58.3% | 48.6% | - |
Health Citation History
9 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2023-11-29 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2023-11-29 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2019-11-06 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2019-11-06 | 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 |
| 2019-11-06 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2019-11-06 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2018-12-05 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2018-12-05 | Quality of Life and Care Deficiencies | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | D – Moderate Harm Potential |
| 2018-12-05 | 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. | D – Moderate Harm Potential |
Fire Safety Citation History
29 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-02-27 | Emergency Preparedness Deficiencies | Develop and maintain an Emergency Preparedness Program (EP). | D – Moderate Harm Potential |
| 2026-02-27 | Emergency Preparedness Deficiencies | Conduct risk assessment and an All-Hazards approach. | D – Moderate Harm Potential |
| 2026-02-27 | Emergency Preparedness Deficiencies | Address subsistence needs for staff and patients. | D – Moderate Harm Potential |
| 2026-02-27 | Emergency Preparedness Deficiencies | Establish policies and procedures including evacuation. | D – Moderate Harm Potential |
| 2026-02-27 | Emergency Preparedness Deficiencies | Create arrangements with other facilities to receive patients. | D – Moderate Harm Potential |
| 2026-02-27 | Emergency Preparedness Deficiencies | Establish roles under a Waiver declared by secretary. | D – Moderate Harm Potential |
| 2026-02-27 | Emergency Preparedness Deficiencies | List the names and contact information of those in the facility. | D – Moderate Harm Potential |
| 2026-02-27 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | D – Moderate Harm Potential |
| 2026-02-27 | Emergency Preparedness Deficiencies | Implement emergency and standby power systems. | D – Moderate Harm Potential |
| 2026-02-27 | Egress Deficiencies | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | D – Moderate Harm Potential |
| 2026-02-27 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2026-02-27 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | D – Moderate Harm Potential |
| 2026-02-27 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | D – Moderate Harm Potential |
| 2026-02-27 | Smoke Deficiencies | Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | D – Moderate Harm Potential |
| 2026-02-27 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | D – Moderate Harm Potential |
| 2026-02-27 | Miscellaneous Deficiencies | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | D – Moderate Harm Potential |
| 2026-02-27 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | D – Moderate Harm Potential |
| 2026-02-27 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure that testing and maintenance of electrical equipment is performed. | D – Moderate Harm Potential |
| 2019-11-06 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | F – Moderate Harm Potential |
| 2019-11-06 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | E – Moderate Harm Potential |
| 2019-11-06 | Egress Deficiencies | 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. | D – Moderate Harm Potential |
| 2019-11-06 | Egress Deficiencies | Install proper backup exit lighting. | D – Moderate Harm Potential |
| 2019-11-06 | Egress Deficiencies | Have properly located and lighted "Exit" signs. | D – Moderate Harm Potential |
| 2019-11-06 | Smoke Deficiencies | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | D – Moderate Harm Potential |
| 2019-11-06 | Gas, Vacuum, and Electrical Systems Deficiencies | Meet requirements for the use of electrical equipment. | D – Moderate Harm Potential |
| 2018-12-05 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2018-12-05 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2018-12-05 | Smoke Deficiencies | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | F – Moderate Harm Potential |
| 2018-12-05 | Smoke Deficiencies | Provide properly protected cooking facilities. | D – Moderate Harm Potential |
Total Penalties & Fines
$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties
No penalty records found.
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3-Year Complete Report ($19)
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the SHELBYVILLE area at no cost.
Find Safe, Vetted Facilities Near SHELBYVILLE
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.