Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Johnson City, Llc during CMS and state inspections, most recent first.
The facility failed to resubmit a PASARR in a timely manner for two residents after new mental health diagnoses were identified. One resident was admitted with PTSD and Major Depressive Disorder, while another was readmitted with PTSD. Despite the facility's policy requiring a new PASARR after new diagnoses, this was not completed, as confirmed by the administrator.
A facility failed to develop and implement Enhanced Barrier Precautions (EBP) for three residents, leading to deficiencies in care. One resident with an indwelling urinary catheter, another with a pressure ulcer, and a third receiving dialysis services lacked EBP signage and PPE. The Assistant Director of Nursing confirmed these oversights, and the Director of Nursing acknowledged the unmet expectations for EBP.
A resident was found with unsecured medications in their room without an assessment or physician's order for self-administration, contrary to facility policy. The resident, who was cognitively intact, had medications such as artificial tears, zinc oxide, and triple magnesium vitamins, which were confirmed by the ADON to be unsecured and not assessed for safe storage or self-administration.
The facility failed to maintain and store respiratory care equipment properly for residents receiving oxygen and nebulizer treatments. A resident's oxygen tubing and humidifier bottle were not changed weekly, and nebulizer equipment for two residents was found uncovered and not stored in a bag. Staff confirmed these deficiencies, acknowledging the equipment should have been labeled, dated, and stored according to policy.
A resident requiring dialysis services did not have dialysis communication sheets completed and sent with her to treatments, as per facility policy. The resident, who was cognitively intact, confirmed the absence of these sheets. Interviews revealed that staff were unaware of the requirement, and the DON acknowledged the expectation to send such sheets with residents.
The facility failed to properly contain garbage in Dumpster A, as observed during a survey. The facility's trash disposal policy requires closed dumpster lids and cleanliness to prevent pests. However, the lid of Dumpster A was left open, exposing contents to the elements, and the surrounding area was unsanitary with trash and debris. The Certified Dietary Manager confirmed these issues.
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents with indwelling medical devices and wounds. Observations revealed the absence of EBP signage and PPE for these residents, despite facility policy requiring such measures. The DON confirmed the deficiency prior to the surveyor's observations.
Failure to Resubmit PASARR After New Mental Health Diagnoses
Penalty
Summary
The facility failed to resubmit a Pre-Admission Screening and Resident Review (PASARR) in a timely manner after new mental health diagnoses were identified for two residents. According to the facility's policy, PASARR is a federally mandated process that requires pre-screening of all residents seeking admission to a Medicaid-funded nursing facility to identify those with mental illness, ensure appropriate placement, and provide necessary services. However, the facility did not adhere to this policy for Resident #30 and Resident #14, who both had new mental health conditions that were not followed by a timely PASARR submission. Resident #30 was admitted with new diagnoses of Post Traumatic Stress Disorder (PTSD) and Major Depressive Disorder, but a new PASARR was not submitted after these diagnoses were added. Similarly, Resident #14, who was readmitted with PTSD, did not have a new PASARR submitted despite the presence of a care plan for trauma and PTSD. The facility's administrator confirmed that it was expected for a new PASARR to be completed after identifying new mental health conditions, but this was not done for the two residents in question.
Failure to Implement Enhanced Barrier Precautions for Residents
Penalty
Summary
The facility failed to develop and implement Enhanced Barrier Precautions (EBP) care plans for three residents, leading to deficiencies in their care. Resident #9, who was admitted with diagnoses including Obstructive and Reflux Uropathy, Diabetes Mellitus, and Dementia, had an indwelling urinary catheter but lacked EBP signage and Personal Protective Equipment (PPE) in or outside their room. Despite having a care plan for the catheter, the necessary precautions were not implemented. Similarly, Resident #32, with a pressure ulcer on the right heel, did not have EBP developed prior to the observation date, and there was no signage or PPE available. This resident had moderate cognitive impairment and required wound care for an unhealed stage 4 pressure ulcer. Resident #38, who was cognitively intact and received dialysis services, also lacked EBP development in their care plan. Observations revealed no EBP signage or PPE for the resident, who had a central venous hemodialysis access port. The Assistant Director of Nursing confirmed the absence of EBP signage and PPE for all three residents, and the Director of Nursing acknowledged that the facility's expectations for EBP were not met. These oversights in care planning and implementation were identified during facility observations and interviews.
Failure to Secure Medications for Resident
Penalty
Summary
The facility failed to secure medications for a resident, leading to a deficiency in medication storage and supervision. The facility's policy on medication self-administration requires an assessment and physician's order for residents who wish to self-administer medications. However, Resident #4, who was cognitively intact as per the Brief Interview for Mental Status (BIMS) assessment, was not assessed or care planned for self-medication storage and self-administration. Despite this, Resident #4 had medications, including artificial tears, zinc oxide, and triple magnesium vitamins, in their room without a physician's order for self-administration. During an observation, the Assistant Director of Nursing (ADON) confirmed that these medications were not secured and that Resident #4 had not been assessed for medication storage and self-administration. The resident stated that their son brought the medications, and they administered them independently. The facility's failure to assess and secure the medications in Resident #4's room constitutes a deficiency in ensuring a safe environment free from accident hazards, as required by the facility's policy.
Deficiencies in Respiratory Care Equipment Maintenance
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the maintenance and storage of respiratory care equipment for residents receiving oxygen and nebulizer treatments. Specifically, the facility did not label and date the oxygen tubing for one resident and failed to change the oxygen tubing and humidifier bottle weekly for another resident. Additionally, the facility did not properly store the handheld nebulizer equipment for two residents, as the equipment was found uncovered and not stored in a bag as required by the facility's policy. Resident #2, who has a history of respiratory conditions including COPD and asthma, was observed with oxygen tubing and a humidifier bottle dated 11 days prior, indicating they had not been changed weekly as required. The resident's nebulizer mouthpiece was also found uncovered and not stored in a bag. Similarly, Resident #176, who also has COPD, was observed with undated oxygen tubing and uncovered nebulizer equipment. Interviews with facility staff, including an LPN and the ADON, confirmed these deficiencies, acknowledging that the equipment should have been labeled, dated, and stored properly.
Failure to Complete Dialysis Communication Records
Penalty
Summary
The facility failed to complete dialysis communication records for a resident requiring dialysis services. The facility's policy on community hemodialysis mandates the use of a dialysis communication sheet to ensure coordination of care for residents undergoing hemodialysis. However, it was found that Resident #38, who was admitted with diagnoses including End Stage Renal Disease, Hemiplegia, and Stroke, did not have these communication sheets completed and sent with her to dialysis sessions. The resident, who was cognitively intact, confirmed that she did not take a dialysis communication sheet with her to the dialysis services. Interviews with facility staff revealed a lack of awareness and adherence to the policy. An LPN stated that she sent a face sheet with diagnoses and a list of medications with the resident but was unaware of the requirement for a dialysis communication sheet. The Medical Records Director confirmed the absence of documentation for these sheets, and the DON acknowledged that it was the facility's expectation to send such sheets with residents for each dialysis treatment. This oversight indicates a failure in the facility's process to ensure proper communication and coordination of care for residents receiving dialysis services.
Improper Garbage Disposal and Unsanitary Conditions
Penalty
Summary
The facility failed to ensure proper containment of garbage and refuse in one of its dumpsters, Dumpster A, as observed during a survey. The facility's policy on trash disposal, dated August 23, 2023, mandates that the Food Service department is responsible for disposing of trash appropriately and maintaining the cleanliness of the dumpster area to prevent rodent infestation. This includes ensuring that dumpster lids are closed and that no trash is left on the ground surrounding the dumpsters. However, during an observation on February 23, 2025, it was noted that the lid of Dumpster A was not closed, leaving its contents exposed to the elements and potential pests. Additionally, the area around Dumpster A was found to be unsanitary, with a trash bag hanging from the dumpster, used disposable gloves, a milk carton, and various pieces of paper debris scattered on the ground. The Certified Dietary Manager confirmed these observations during an interview, acknowledging that the dumpster lid was not closed and the area was not maintained in a sanitary condition.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents who required such measures due to their medical conditions. Resident #9, who had an indwelling urinary catheter, did not have EBP signage or Personal Protective Equipment (PPE) available in or outside their room. Similarly, Resident #32, who had a pressure ulcer wound, also lacked EBP signage and PPE availability. Resident #38, with a central venous hemodialysis access port, was observed without the necessary EBP signage or PPE in or outside their room. The facility's policy, revised in December 2022, mandates the use of appropriate PPE and EBP signage for residents with indwelling medical devices, wounds, or central venous catheters. Despite this policy, observations and interviews confirmed the absence of EBP signage and PPE for the three residents. The Director of Nursing (DON) acknowledged the expectation for EBP measures to be in place for these residents and confirmed the deficiency prior to the surveyor's observations.
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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 Johnson City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Agape Rehabilitation & Nursing Center, A Waters Cm | 1.3 mi | ★★★★★ | 0 | 0 |
| Abundant Christian Living Community Rehabilitation | 1.5 mi | ★★★★★ | 0 | 0 |
| Princeton Transitional Care & Assisted Living | 1.9 mi | ★★★★★ | 2 | 0 |
| Lakebridge, A Waters Community, Llc | 1.9 mi | ★★★★★ | 0 | 0 |
| Nhc Healthcare, Johnson City | 2.2 mi | ★★★★★ | 3 | 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.