Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Waters Of Gallatin during CMS and state inspections, most recent first.
An LPN failed to properly clean and dry a resident’s nebulizer mouthpiece and medication cup after treatment, instead wiping the equipment with a paper towel and placing it in a plastic bag while still connected. The facility also had no monthly infection tracking and trending report for one month, and the ICP confirmed the missing report during review.
A resident with COPD, depression, and adult failure to thrive died, and the facility did not refund the remaining resident trust fund balance within the required 30-day timeframe. Review showed a returned check for $1,285.81 was issued 33 days after the deadline. The BOM stated the timeframe was overlooked, and the Administrator confirmed the funds should have been sent within 30 days.
Failure to provide required annual CNA in-service training was cited after review showed 4 of 11 CNAs did not receive the required 12 hours based on their hire-date training year. Facility policy required each nurse aide to complete 12 hours annually, but records showed CNA A, B, C, and D completed only 8, 7, 6, and 7 hours, respectively. The DON and Staffing Coordinator both confirmed the annual training requirement.
Unattended Nebulizer Treatment and Improper Equipment Cleaning: A resident with COPD, HF, and anxiety received a DuoNeb treatment while holding the mouthpiece in his mouth with no nurse present, even though the DON stated he had not been assessed to self-administer meds. After the treatment, an LPN wiped the mouthpiece with a paper towel and placed it in a bag with the nebulizer cup still attached, rather than separating, rinsing, and air-drying the parts as required by policy.
Improper Storage of Food in Patient & Family and Bistro Refrigerators: The facility failed to store resident food according to policy when the Patient & Family refrigerator and Bistro refrigerator contained multiple unlabeled, undated, expired, and uncovered items. Observations found an opened can of lemonade, expired nutritional supplements and yogurt, undated containers and sandwiches, and 5 undated roast beef and cheese sandwiches in the Bistro fridge. An LPN and the CDM stated these items should not have been in the refrigerators.
CNA Annual In-Service Training Deficiency: The facility failed to ensure 4 of 11 CNAs completed the required 12 hours of annual in-service training based on their hire dates. Review of records showed CNA A, B, C, and D each completed fewer than 12 hours during their respective 12-month training periods, and both the DON and Staffing Coordinator confirmed the annual training requirement.
A resident with a history of Hemiplegia and Major Depressive Disorder alleged sexual abuse by staff after being transferred to a hospital for psychiatric evaluation. Despite the facility's policy requiring immediate reporting and investigation of abuse allegations, the Social Services Director did not notify the Administrator, and no investigation was conducted. The hospital reported the allegations to APS and the police, indicating a significant lapse in the facility's response to the allegations.
A resident with a history of falls and osteoporosis slid out of an inappropriate transport chair after staff failed to heed her warnings and provide adequate supervision. Despite the resident's repeated alerts, staff did not use a mechanical lift or perform an immediate assessment for injuries, leading to her fall. The incident revealed lapses in safety measures and staff training at the facility.
A facility failed to ensure nursing staff had the necessary competencies to care for a resident with a tracheostomy. Despite the Facility Assessment Tool's requirement for specialized education, staff were inadequately trained, as revealed through interviews with LPNs and the ADON. The interim DON's brief in-service training was insufficient, and the NP raised concerns about staff handling acute airway emergencies. The resident, who had no cognitive impairment, was providing his own trach care without a physician's order, highlighting the staff's lack of training and confidence.
Improper Cleaning of Nebulizer Equipment and Missing Infection Tracking Report
Penalty
Summary
The facility failed to ensure infection prevention and control for Resident #97 when reusable nebulizer equipment was not properly cleaned after treatment. Resident #97 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Heart Failure, and Anxiety, and the quarterly MDS assessment showed a Brief Interview for Mental Status score of 15, indicating he was cognitively intact. A physician order dated 1/29/2026 directed Ipratropium-Albuterol inhalation solution every 4 hours for shortness of breath. During observation at the resident’s doorway, an LPN removed the nebulizer mouthpiece from the resident, disconnected the tubing, wiped the mouthpiece with a brown paper towel, and placed the mouthpiece with the nebulizer medication cup still connected into a plastic bag. The LPN did not separate the mouthpiece and nebulizer medication cup, rinse them, or allow them to air dry on a barrier before storage, which was inconsistent with facility policy. The facility also failed to establish and implement infection surveillance tracking and trending for February 2026. Facility policy stated that infection surveillance is a core activity of the infection control program, that monthly time periods are used for capturing and reporting data, and that all residents and infections are tracked. Review of the infection tracking and trending reports showed no report for February 2026. The ICP confirmed that tracking and trending were available for December 2025 and January 2026 but not for February 2026, and stated that the February 2026 report should have been present.
Failure to Timely Convey Resident Trust Funds After Death
Penalty
Summary
The facility failed to reimburse resident funds within 30 days after death for 1 of 1 sampled residents reviewed for personal fund accounts. The facility policy titled, Conveyance of Resident Funds Upon Death, stated that upon the death of a resident with personal funds deposited with the facility, the funds and a final accounting must be conveyed within 30 days to the individual or probate jurisdiction administering the resident’s estate. Resident #101 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Depression, and Adult Failure to Thrive, and later died. Review of the resident trust fund account showed a returned check for the account balance of $1,285.81, and 33 days had passed beyond the allotted 30-day timeframe before the balance was refunded to the resident’s estate. During interview, the Business Office Manager stated the 30-day timeframe was overlooked, and the Administrator stated the funds should have been sent within 30 days and completed in that time.
Failure to Provide Required Annual CNA In-Service Training
Penalty
Summary
Provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift was cited after the facility failed to ensure 4 of 11 CNAs received at least 12 hours of required annual in-service training. Review of the facility policy titled Nurse Aide Training Program showed each nurse aide was to receive at least 12 hours of in-service training annually based on the employee's hire date, and documentation was to be maintained by the Staff Development Coordinator during the training year and then forwarded to HR for the personnel file. Review of CNA in-service records showed CNA A, hired on 1/31/2002, completed 8 hours from 1/31/2025 to 1/31/2026; CNA B, hired on 10/7/2021, completed 7 hours from 10/7/2024 to 10/7/2025; CNA C, hired on 12/27/2024, completed 6 hours from 12/27/2024 to 12/27/2025; and CNA D, hired on 6/6/2022, completed 7 hours from 6/6/2024 to 6/6/2025. During interviews, the DON and the Staffing Coordinator both stated that CNAs should have 12 in-service hours during a 12-month period beginning on the hire date annually.
Unattended Nebulizer Treatment and Improper Equipment Cleaning
Penalty
Summary
Medication storage and nebulizer therapy were not carried out in accordance with facility policy for Resident #97, who was admitted with COPD, heart failure, and anxiety and was documented as cognitively intact on the quarterly MDS. The resident had an order for DuoNeb inhalation solution every 4 hours for shortness of breath. During observation, the resident was holding the nebulizer mouthpiece in his mouth while receiving treatment, and no nurse was in the room. The DON stated the nurse should have been with the resident the entire time because the resident had not been assessed to self-administer medications. After the treatment, LPN E removed the mouthpiece from the resident and disconnected the tubing, then wiped the mouthpiece with a brown paper towel and placed the mouthpiece with the nebulizer cup still attached into a plastic bag. The LPN did not separate the mouthpiece from the nebulizer cup, rinse the parts, or allow them to air dry on a barrier before storage. The DON stated the mouthpiece and chamber should be separated, rinsed, and allowed to dry, and explained this was for infection control to prevent buildup of bacteria in the chamber. LPN E stated she wiped it out with the paper towel and put it in the bag.
Improper Storage of Food in Patient & Family and Bistro Refrigerators
Penalty
Summary
The facility failed to properly store resident food in the Patient & Family refrigerator and the Bistro refrigerator. During review of facility policies and refrigerator notices, the facility had written expectations that prepared food brought in by family or visitors must be labeled with content and date, that refrigerated food should be labeled, dated, and monitored, and that foods should be kept covered or in tight containers. The Patient & Family Fridge Notice also stated that items must be clearly labeled with the patient's name and date, while the Bistro Fridge Notice stated that items placed in that refrigerator must be properly labeled with a date. During observation of the Patient & Family refrigerator, multiple food and beverage items were found unlabeled, undated, expired, or uncovered, including an opened can of lemonade, nutritional supplements with use-by dates of 1/19/2026, undated containers of salad, unknown food items, a chicken salad sandwich and potato salad with a sell-by date of 3/23/2026, undated pizza, yogurts with use-by dates of 3/26/2026 and 3/29/2026, and several other unlabeled or undated food items. The Bistro refrigerator contained 5 undated roast beef and cheese sandwiches wrapped in plastic. An LPN and the CDM both stated that unlabeled, undated, expired, or uncovered food items should not be in these refrigerators.
CNA Annual In-Service Training Deficiency
Penalty
Summary
The facility failed to ensure that 4 of 11 CNAs received at least 12 hours of required annual in-service training. Facility policy stated that each nurse aide shall be provided at least 12 hours of in-service training annually based on the employee’s hire date, and documentation is to be maintained by the Staff Development Coordinator and forwarded to HR at the end of the training year. Review of CNA in-service records showed that CNA A, hired 1/31/2002, completed 8 hours from 1/31/2025 to 1/31/2026; CNA B, hired 10/7/2021, completed 7 hours from 10/7/2024 to 10/7/2025; CNA C, hired 12/27/2024, completed 6 hours from 12/27/2024 to 12/27/2025; and CNA D, hired 6/6/2022, completed 7 hours from 6/6/2024 to 6/6/2025. During interviews, the DON and Staffing Coordinator both stated that CNAs should have 12 in-service hours during a 12-month period beginning on the hire date annually.
Failure to Investigate Allegations of Sexual Abuse
Penalty
Summary
The facility failed to initiate an investigation into allegations of sexual abuse involving a resident, despite having a policy in place that mandates such actions. The facility's policy, titled 'ABUSE PREVENTION PROGRAM,' requires that any incident or allegation of abuse be promptly reported and investigated. However, in the case of Resident #6, who was admitted with diagnoses including Hemiplegia, Hemiparesis, and Major Depressive Disorder, the facility did not follow through with these procedures. The resident was transferred to a hospital for psychiatric evaluation after expressing suicidal ideations, where she alleged sexual abuse by staff at the facility. Interviews revealed a breakdown in communication and procedure adherence. The Social Services Director (SSD) was informed of the allegations by Adult Protective Services (APS) but did not ensure that the Administrator was notified, nor was an investigation initiated. The Administrator confirmed that he was unaware of the allegations and that no investigation had been conducted. The hospital's social worker reported the allegations to APS and the local police, highlighting the facility's failure to act on serious allegations of abuse, as required by their own policies.
Resident Falls Due to Inadequate Supervision and Equipment
Penalty
Summary
The facility failed to provide an environment free from accident hazards for Resident #10, who was at risk for falls and serious injury due to her medical conditions, including Chronic Obstructive Pulmonary Disease (COPD), Generalized Anxiety Disorder, and osteoporosis. On the day of the incident, Resident #10 was placed in a transport chair that was not suitable for her size, leading to her sliding out of the chair. Despite her repeated verbal warnings to the staff that she was sliding and about to fall, the staff did not take immediate corrective action to ensure her safety. The video footage and interviews revealed that the staff, including CNAs and an LPN, failed to properly assess and address the situation. CNA M, who was responsible for transporting Resident #10, appeared agitated and did not heed the resident's warnings. Instead of using a mechanical lift or a more appropriate chair, CNA M attempted to pull the resident backwards in the transport chair, causing her to slide out onto the floor. The staff did not perform an immediate assessment for injuries, and there was a lack of coordination and communication among the staff members present. The facility's protocol required a nurse to perform a head-to-toe assessment after a fall, which was not done before moving Resident #10. The incident report and interviews indicated that the staff did not follow the facility's guidelines for incidents and accidents, which contributed to the deficiency. The failure to provide adequate supervision and an appropriate environment for Resident #10 resulted in her sliding out of the chair and onto the floor, highlighting a significant lapse in the facility's safety measures and staff training.
Inadequate Tracheostomy Care Training for Nursing Staff
Penalty
Summary
The facility failed to ensure that all nursing staff possessed the necessary competencies and skill sets to provide adequate care for a resident with a tracheostomy. The Facility Assessment Tool indicated that specialized education should be provided to staff for managing new or less common diagnoses, such as tracheostomy care. However, the facility did not adequately prepare its staff for the care of Resident #5, who was admitted with a tracheostomy and other complex medical conditions. The facility's policy on tracheostomy care required aseptic cleaning and proper suctioning techniques, but these were not effectively communicated or practiced by the staff. Interviews with various staff members, including LPNs and the ADON, revealed a lack of confidence and training in tracheostomy care. LPN E expressed concerns about not having the experience or training to care for a trach patient and noted the absence of necessary equipment like suction machines and trach care kits. The interim DON attempted to provide a brief in-service training, which included a true/false quiz and a video, but this was deemed insufficient by the staff. The NP also raised concerns about the staff's ability to handle acute airway emergencies, indicating that the training provided was inadequate. Resident #5, who had no cognitive impairment, was reportedly providing his own trach care without a physician's order for self-care. The staff's lack of training and confidence in handling tracheostomy care was further highlighted by their reliance on the resident to manage his own care. The DON acknowledged that the competency check-off sheet used during orientation was not sufficient for ensuring staff competency in tracheostomy care, and the in-service quiz was confirmed to be inadequate training.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Gallatin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gallatin Center For Rehabilitation And Healing | 0.8 mi | ★★★★★ | 0 | 0 |
| Nhc Place Sumner | 5 mi | ★★★★★ | 3 | 0 |
| Signature Health Of Portland Rehab & Wellness Cent | 9.7 mi | ★★★★★ | 17 | 0 |
| Nhc Healthcare, Hendersonville | 11.3 mi | ★★★★★ | 4 | 1 |
| Pavilion-ths, Llc | 13 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.