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 Smyrna, Llc during CMS and state inspections, most recent first.
The facility failed to protect three residents from sexual abuse by another resident, resulting in Immediate Jeopardy. Despite reports of nonconsensual advances and inappropriate touching, the administration did not implement effective interventions or document the abuse promptly. The affected residents, with varying cognitive impairments, expressed fear and discomfort, but their care plans lacked necessary interventions to address the abuse.
The facility failed to investigate and address allegations of sexual abuse by a resident, affecting three other residents. Despite reports of nonconsensual advances and inappropriate behavior, the facility did not conduct investigations or implement care plan interventions. Staff and residents reported ongoing issues, but the facility's inaction led to Immediate Jeopardy, posing a risk of serious harm.
A resident with severe cognitive impairment was improperly restrained in a geriatric chair with a tray table, inhibiting her movement without a physician's order or proper documentation. The facility failed to assess, care plan, or monitor the restraint, leading to a skin tear and Immediate Jeopardy. Staff interviews revealed a lack of training and awareness regarding the restraint's use.
The facility failed to provide adequate staffing, resulting in delayed care and unmet needs for residents. Observations and interviews revealed that staffing levels were insufficient, particularly on weekends, leading to long wait times for assistance and residents being fed in hallways. Several residents with cognitive and physical impairments were affected, highlighting the facility's inability to meet its policy of providing care based on resident needs.
The facility failed to ensure staff competency, leading to inadequate care for two residents. One resident was not properly attended to during a medical emergency, and another was given medication incorrectly and restrained without proper documentation. The facility did not follow its policies on physical restraints and physician orders, resulting in deficiencies in resident care.
The facility failed to ensure food safety and sanitation, affecting all residents. Observations revealed unclean ice machines with debris, incomplete refrigerator temperature logs, and improperly labeled and outdated food items in nourishment rooms. These issues indicate a failure to adhere to food safety protocols.
The facility failed to report allegations of sexual abuse involving three residents and neglect involving another resident to the State Survey Agency. Despite reports of nonconsensual advances and neglect, no interventions were documented, and staff were aware of the issues but did not take action. The facility's inaction highlights a deficiency in adhering to their abuse prevention policy.
A resident with severe cognitive impairment was placed in a geriatric chair with a tray, which was not documented as a restraint. Facility staff failed to conduct proper assessments or obtain necessary documentation, leading to a deficiency in care assessment. The MDS Coordinator relied on incomplete charted information, and the DON could not provide a physician's order or consent for the restraint.
The facility failed to implement comprehensive care plans for residents, neglecting to address sexual abuse incidents involving a resident and the improper use of physical restraints for another. Despite reports of inappropriate touching and propositions, care plans lacked necessary interventions. Additionally, the use of a geriatric chair as a restraint was not properly documented or assessed, violating facility policy.
A resident with Alzheimer's, anxiety, and seizures was prescribed Lorazepam for seizure activity, but it was administered without documented seizure activity, often for agitation. Facility staff misunderstood the medication's intended use, administering it for behaviors like restlessness. Interviews with hospice and facility staff revealed concerns about the inappropriate use and lack of documentation, highlighting a failure to follow physician's orders and professional standards.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect three vulnerable residents from sexual abuse by another resident, resulting in Immediate Jeopardy. Residents reported nonconsensual sexual advances and inappropriate touching by a fellow resident, who had a history of such behavior. Despite being informed of these incidents, the facility's administration did not implement effective interventions or document the abuse in a timely manner. Resident #6, who had no cognitive impairment, reported that Resident #10 made nonconsensual sexual advances by touching her hair and rubbing her thighs. She expressed fear and discomfort around Resident #10, who continued to antagonize her during activities. Resident #7, with moderate cognitive impairment, also reported unwanted sexual propositions and touching by Resident #10. Both residents had informed the facility's administration, but no interventions were added to their care plans to address the abuse. Resident #18, who also had no cognitive impairment, reported that Resident #10 entered her room and demanded a kiss. Despite notifying the Administrator, DON, and Activities Director, no immediate action was taken to address the situation. The facility's failure to document and address these incidents in a timely manner, as well as the lack of interventions in the residents' care plans, contributed to the ongoing risk of abuse.
Failure to Investigate Allegations of Sexual Abuse
Penalty
Summary
The facility failed to conduct an investigation and take appropriate corrective actions for allegations of sexual abuse involving three residents. Resident #6, who had no cognitive impairment and a diagnosis of Spastic Quadriplegia with Cerebral Palsy, reported that Resident #10 made nonconsensual sexual advances by touching her hair and rubbing her thighs. Despite reporting these incidents to the Administrator and DON, no investigation was conducted, and the behavior continued, causing Resident #6 to feel fearful and uncomfortable. Resident #7, with moderate cognitive impairment, also reported nonconsensual sexual propositions and unwanted physical contact from Resident #10. She expressed discomfort and a desire to avoid Resident #10, but the facility did not investigate her allegations. Similarly, Resident #18 reported an incident where Resident #10 entered her room and demanded a kiss, which she reported to the facility's leadership. Again, no investigation was conducted, and the facility failed to implement interventions to address these allegations in the residents' care plans. Interviews with staff, including the Activities Director and the Ombudsman, revealed a pattern of inappropriate behavior by Resident #10, which was reported to the Administrator and DON. Despite being aware of these issues, the facility did not take action to separate Resident #10 from the affected residents or document the incidents. The facility's inaction resulted in Immediate Jeopardy, as the noncompliance with regulatory requirements posed a risk of serious harm to the residents.
Failure to Provide Restraint-Free Environment
Penalty
Summary
The facility failed to provide an environment free from the use of physical restraints for a resident, who was severely cognitively impaired and vulnerable. The resident was observed multiple times sitting in a geriatric chair with a connected tray table across her lap, which she was unable to release, thus inhibiting her freedom of movement. This restraint was used without a physician's order, without documentation of the medical symptom necessitating the restraint, and without evidence of less restrictive alternatives being tried first. Additionally, there was no documentation of direct monitoring or supervision during the use of the restraint, nor was there an assessment, care plan, or re-evaluation of the need for the restraint. The resident, who had Alzheimer's Disease, Anxiety Disorder, and Seizures, was admitted to the facility without an order for the table tray attached to the geriatric chair. Despite the facility's policy requiring a complete order for restraints, including the type and timing of application and release, no such order existed for this resident. Observations revealed that the resident was often left with the tray table across her lap without any activities or supplies, and she was unable to remove it herself. The resident sustained a skin tear on her right lower leg, which was reinjured, resulting in Immediate Jeopardy with actual harm. Interviews with staff and family members revealed a lack of training and awareness regarding the use of the geriatric chair and tray as a restraint. Staff members were unaware of any assessments or orders for the restraint, and the family member did not request the chair but was informed it would help reduce falls. The facility's failure to document and assess the use of the restraint, along with the lack of a care plan and monitoring, contributed to the deficiency and the harm experienced by the resident.
Staffing Deficiencies Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient staff to meet the needs of its residents, as evidenced by multiple observations and interviews. The facility's policy requires staff assignments to be based on resident needs, including physical, emotional, psychosocial, social, and spiritual care. However, the Payroll Based Journal (PBJ) Staffing Data Report indicated a one-star staffing rating and excessively low weekend staffing for several quarters in 2023 and 2024. The facility assessment showed a high percentage of residents requiring assistance with activities of daily living, yet staffing levels were inadequate to meet these needs. Observations on specific dates revealed that there were only four nurses and three CNAs available to care for 73 residents, resulting in delayed assistance with meals and personal care. Residents and family members reported long wait times for assistance, with some residents waiting up to 45 minutes or more for help with call lights. Interviews with staff confirmed that the facility was often short-staffed, particularly on weekends, leading to residents not receiving timely care and assistance. Several residents with varying degrees of cognitive and physical impairments were affected by the staffing deficiencies. For instance, one resident with severe cognitive impairment required extensive assistance with daily activities but was often left unattended during meals. Another resident with no cognitive impairment reported waiting long periods for assistance, using multiple phones and a clock to track the time. The lack of sufficient staff also led to residents being fed in hallways rather than in a dining room, which remained closed due to staffing shortages.
Inadequate Staff Competency and Improper Use of Restraints
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had the appropriate competencies to care for residents, leading to deficiencies in the care of two residents. Resident #1, who had severe cognitive impairment and was a full code status, was found with decreased vital signs, but the nursing staff did not follow the expected protocol of contacting the physician or initiating emergency procedures. The DON documented the resident's passing without notifying the physician, and the family was not informed of the resident's condition prior to death. Resident #15, who had severe cognitive impairment and required substantial assistance, was inappropriately administered Lorazepam for agitation instead of its intended use for seizures. The nursing staff, including LPN JJJ and RN X, misunderstood the medication's purpose and did not notify the physician of the resident's condition. Additionally, Resident #15 was placed in a geriatric chair with a table tray, which acted as a physical restraint without proper assessment, documentation, or physician's order. The resident was unable to remove the tray, and there was no documentation of when the restraint was released. The facility's policies on physical restraints and physician orders were not followed, as evidenced by the lack of documentation and assessment for the use of restraints on Resident #15. The DON and other staff members were unable to provide necessary documentation or verify staff training related to the use of the geriatric chair with a table tray. The facility's failure to adhere to its policies and ensure staff competency resulted in inadequate care and safety measures for the residents involved.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to minimize the potential for foodborne illness transmission by not properly cleaning and sanitizing the inner components of the ice machine, affecting all 73 residents. Observations revealed pink colored debris inside the ice machine in the 400 Hall nourishment room, which was confirmed by both the Dietary Manager and the Director of Nursing. The Administrator instructed the Maintenance Director to take the ice machine out of service. Additionally, the facility did not document refrigerator temperatures to ensure food safety in 3 of the 3 nourishment room refrigerators, potentially affecting all residents. Temperature logs for May 2024 showed incomplete records, with many days lacking temperature documentation. Observations in various nourishment rooms revealed outdated and improperly labeled food items, including condiments, juices, and nutritional supplements, with no open or use-by dates. The facility's policies required daily temperature recordings and proper labeling of food items, but these were not adhered to. Observations on multiple dates showed continued issues with unlabeled and outdated food items, as well as unclean conditions in the refrigerators, such as brown debris at the bottom of the refrigerator in the 200 Hall nourishment room. These deficiencies indicate a failure to follow established food safety protocols, potentially compromising resident safety.
Failure to Report Abuse and Neglect Allegations
Penalty
Summary
The facility failed to report allegations of sexual abuse involving three residents to the State Survey Agency (SSA). Resident #6, diagnosed with Spastic Quadriplegia with Cerebral Palsy, reported nonconsensual sexual advances by Resident #10, including touching her hair and rubbing her thighs. Despite reporting these incidents to the Administrator and Director of Nursing (DON), no interventions were documented in her care plan. Similarly, Resident #7, with Parkinson's Disease and moderate cognitive impairment, reported unwanted sexual propositions and touching by Resident #10, which were also not addressed in her care plan. Resident #18 reported an incident where Resident #10 demanded a kiss and entered her room without consent, yet no interventions were documented. The facility also failed to report an allegation of neglect involving Resident #9, who was tearful and reported neglect to law enforcement during a welfare check. Resident #9, a medically complex individual with End Stage Renal Disease and Type 1 Diabetes Mellitus, alleged she did not receive her medication as scheduled and felt inadequately cared for. The police report indicated that Resident #9 feared retaliation from staff and had attempted to contact her nurse, LPN B, without success. The Regional Director of Operations confirmed that the neglect allegation should have been reported to the SSA within the required timeframe but was not. Interviews with staff, including the DON, Administrator, and Activities Director, revealed awareness of Resident #10's inappropriate behaviors, yet no actions were taken to address these issues or report them to the state. The Activities Director reported witnessing Resident #10's inappropriate touching during activities and had informed the Administrator and DON, who stated that nothing could be done as long as no one was hurt. The facility's failure to report these incidents and implement appropriate interventions highlights a significant deficiency in adhering to their abuse prevention policy.
Failure to Accurately Assess and Document Use of Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident received an accurate assessment by qualified staff, specifically regarding the use of physical restraints. The Resident Assessment Instrument (RAI) was not properly utilized to assess whether a device met the definition of a physical restraint. The resident in question, who had severe cognitive impairment due to Alzheimer's Disease, was observed in a geriatric chair with a tray that she could not remove without assistance. This setup was not documented as a restraint in the resident's care plan or Minimum Data Set (MDS). Interviews with facility staff revealed a lack of proper documentation and assessment regarding the use of the geriatric chair as a restraint. The MDS Coordinator admitted to not conducting a personal assessment and relying solely on charted information, which did not include any documentation of a physician's order, assessment, or monitoring of the restraint. The Director of Nursing (DON) acknowledged that the chair was used for safety reasons but could not provide necessary documentation or consent for its use as a restraint. The facility did not have a specific MDS policy and relied on the RAI manual, which was not adequately followed in this case. The lack of documentation and assessment led to the failure to recognize and code the geriatric chair with a tray as a physical restraint, resulting in a deficiency in the resident's care assessment process.
Failure to Implement Comprehensive Care Plans and Address Sexual Abuse
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan with appropriate interventions for several residents, leading to deficiencies in addressing sexual abuse and the use of physical restraints. Resident #6, who has no cognitive impairment, reported ongoing inappropriate touching by Resident #10, which was not addressed in her care plan. Despite reporting the incidents to the Administrator and DON, no interventions were added to her care plan to address the sexual abuse, and the issue persisted for nearly a year. Similarly, Resident #7, with moderate cognitive impairment, experienced nonconsensual sexual propositions and touching by Resident #10. Her care plan also lacked interventions to address these incidents, despite her reporting them to the Administrator. Resident #10's care plan documented his aggressive behaviors but failed to include interventions for the allegations of sexual abuse, even though he admitted to inappropriate behavior towards other residents. Additionally, the facility did not properly document or assess the use of a physical restraint for Resident #15, who has severe cognitive impairment. The care plan did not reflect the use of a geriatric chair with a tray as a restraint, nor did it include necessary assessments, orders, or documentation of its use. The MDS Coordinator and DON acknowledged the lack of proper documentation and assessment, indicating a failure to comply with facility policy and regulatory requirements.
Inappropriate Administration of Lorazepam for Seizure Activity
Penalty
Summary
The facility failed to follow physician's orders and ensure that Resident #15 received treatment and care in accordance with professional standards of practice. Resident #15, who was admitted with diagnoses including Alzheimer's Disease, Anxiety Disorder, and Seizures, was prescribed Lorazepam to be administered as needed for seizure activity. However, the medication was frequently administered without documented evidence of seizure activity, contrary to the physician's orders. The Medication Administration Record (MAR) and Progress Notes revealed that Lorazepam was given to Resident #15 on multiple occasions without any documentation of seizure activity. Instead, the medication was administered in response to behaviors such as agitation, restlessness, and anxiety. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and a Registered Nurse (RN), indicated a misunderstanding or misapplication of the medication's intended use, with staff administering Lorazepam for agitation rather than for seizures as prescribed. Further interviews with the Hospice Registered Nurse and the Hospice Medical Doctor highlighted concerns about the inappropriate use of Lorazepam. The Hospice RN confirmed that the medication was intended for seizure activity only, and the Hospice MD expressed concern over the lack of documentation of seizure activity when the medication was administered. Additionally, the facility's Pharmacist and Nurse Practitioner noted that the oral administration of Lorazepam was not appropriate for active seizures, suggesting a lack of adherence to professional standards of practice in the administration of the medication.
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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 Smyrna
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Smyrna Care Center | 0.2 mi | ★★★★★ | 1 | 1 |
| Life Care Center Of Hickory Woods | 5.9 mi | ★★★★★ | 6 | 0 |
| Tennessee Veterans Home | 8.5 mi | ★★★★★ | 2 | 0 |
| Stones River Manor, Inc | 9 mi | ★★★★★ | 0 | 0 |
| Antioch Tn Opco, Llc | 9.5 mi | ★★★★★ | 3 | 3 |
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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.