Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Waters Of Sweetwater A Rehabilitation & Nursing during CMS and state inspections, most recent first.
Failure to Follow Monthly Weight Orders: The facility did not follow monthly weight orders for three residents whose records and care plans called for monthly weights. One resident had Adult Failure to Thrive, Protein Calorie Malnutrition, and CHF; another had dementia, DM2, schizoaffective disorder, stroke, and dysphagia; and a third had chronic lung disease, seizures, and PVD. Their last documented weights were months earlier, and the DON confirmed the residents were not weighed during two months and the physician orders were not followed.
An LPN left a medication cart computer screen unlocked while entering a resident's room, leaving the resident's PHI visible to others. The resident had diagnoses including cirrhosis of the liver, history of falling, and muscle weakness. The LPN confirmed the screen was not protected, and the DON stated staff were expected to lock the screen when walking away from the cart.
PASARR screens were not kept accurate for two residents after new mental health diagnoses were identified. One resident with chronic lung disease later developed adjustment disorder with depressed mood, insomnia, and anxiety disorder, and another resident with dementia and a history of alcoholism later had depression, insomnia, PTSD, and hallucinations documented. The DON confirmed no new PASARR was submitted to the state-designated authority after these diagnoses were added.
The facility failed to properly store medications and biologicals in 1 of 2 medication rooms reviewed. Surveyors found an expired FluAd influenza vaccine in the refrigerator, an opened TB ppd vial without an opened date, and multiple expired items including Vacuette vials, povidone-iodine swabs, bacitracin ointment, enteral connectors, and No-Sting skin prep wipes. An LPN confirmed the items were available for resident use, and the DON confirmed TB ppd vials should be dated when opened and discarded within 30 days.
Failure to Perform Hand Hygiene During Meal Tray Service: During lunch tray delivery, CNAs failed to offer hand hygiene to two residents before meals and failed to perform hand hygiene between serving trays to four other residents. The residents had diagnoses including dementia, DM, HF, Parkinson's disease, ESRD, and muscle weakness, and several required assistance with eating and personal hygiene. Staff confirmed the omissions, and the DON confirmed that hand hygiene should be offered before meal service and performed between residents.
The facility did not post accurate daily nurse staffing information as required by BIPA. Observations revealed outdated staffing postings and missing RN hours documentation for several days, despite records showing RN E worked those days. The DON confirmed the failure to update the staffing sheets and document RN hours.
The facility failed to properly seal food items, potentially affecting 69 residents. The policy requires spice jars to be closed and opened food to be stored in airtight containers. An observation revealed unsealed bottles of garlic and onion powder, and a box of quick oats. The Dietary Manager confirmed the improper storage.
A facility failed to refer a resident with PTSD, Anxiety, and Depression for a Level 2 PASRR evaluation. The initial PASRR Level 1 form incorrectly stated no mental health diagnosis was known, despite the resident's documented conditions. The Human Resource Manager confirmed the oversight during an interview.
A resident's care plan was not updated to reflect a reduction in dialysis treatments from three times a week to two, despite the change being known to the DON. The resident, admitted with Chronic Kidney Disease, Congestive Heart Failure, and Diabetes, reported the change during an interview, which was confirmed by the DON.
The facility failed to properly contain garbage and refuse in two dumpsters, as observed during a survey. The dumpster area was found with open entry doors and littered with disposable gloves, broken office chairs, and ripped mattresses, contrary to the facility's trash disposal policy. The Dietary Manager confirmed the unsanitary condition of the area.
A resident with Chronic Kidney Disease, Congestive Heart Failure, and Diabetes had their dialysis schedule reduced from three times a week to twice a week. However, the facility failed to obtain an updated physician order to reflect this change, as confirmed by the DON during a review of medical records and interviews.
A facility failed to follow infection control practices during medication administration for two residents. An RN did not perform hand hygiene or change gloves when required for a resident on enhanced barrier precautions. Additionally, the RN administered a dropped Oxycodone tablet to another resident, despite acknowledging it should have been discarded. The DON confirmed these lapses in standard precautions.
A resident with moderate cognitive impairment was physically assaulted by another resident with severe cognitive impairment and a history of aggression. The incident occurred when the aggressive resident entered the victim's room multiple times, initially unclothed, and later attempted to hit the victim. Despite intervention by the victim's daughter and facility staff, the aggressive resident made contact with the victim's hands and stomach. The facility's investigation confirmed the assault, although no injuries were observed.
Failure to Follow Monthly Weight Orders
Penalty
Summary
The facility failed to follow physician orders for monthly weight monitoring for 3 residents reviewed for weight monitoring. Facility policy stated residents are to be weighed on admission, weekly for three weeks, and then monthly, and the medical records for Residents #32, #40, and #67 each included orders or care plan directions for monthly weights. Resident #32 had diagnoses including Adult Failure to Thrive, Protein Calorie Malnutrition, and Diastolic Congestive Heart Failure, and an annual MDS showed a BIMS score of 13 indicating cognitive intactness. Resident #40 had diagnoses including Dementia, Type 2 Diabetes, Schizoaffective Disorder, Stroke, and Dysphagia, and a quarterly MDS showed a BIMS score of 10 indicating moderate cognitive impairment. Resident #67 had diagnoses including Chronic Lung Disease, Seizures, and Peripheral Vascular Disease, and a quarterly MDS showed a BIMS score of 9 indicating moderate cognitive impairment. Review of the electronic medical record showed the last documented weight for Resident #32 was 5/2/2025 at 131.0 lbs, for Resident #40 was 5/11/2025 at 213.0 lbs, and for Resident #67 was 5/5/2025 at 164.2 lbs. No further weights were documented until the surveyor requested them on 8/5/2025, when the residents were weighed again and showed 130.0 lbs, 211.6 lbs, and 156.2 lbs, respectively. During interview, the NP stated it was her expectation that physician orders were followed, and the DON confirmed that Residents #36, #40, and #67 were not weighed during 6/2025 and 7/2025 and that physician orders were not followed.
Unsecured Resident PHI Left Visible on Medication Cart
Penalty
Summary
The facility failed to keep resident health information private and confidential for one resident during medication administration. Review of the facility policy titled, "What is HIPAA," stated that any and all health information identifying an individual, including electronic records, is to be protected and safeguarded as PHI. Resident #4 was admitted with diagnoses including cirrhosis of the liver, history of falling, and muscle weakness. During an observation and interview on the upper 200 hall, an LPN walked away from the medication cart to enter Resident #4's room and left the computer screen unlocked, displaying the resident's private health information. The LPN later confirmed the screen had been left unlocked and that the resident's private health information was not protected and was available for public view. The DON stated it was the facility's expectation that staff lock the computer screen when walking away from it and confirmed the resident's private health information was not protected when the LPN left the medication cart without locking the screen.
PASARR screens were not updated after new mental health diagnoses were identified
Penalty
Summary
The facility failed to ensure Pre-admission Screening and Resident Review (PASARR) screens were accurate after new mental health diagnoses were identified for two residents. Facility policy stated PASRR is a federally mandated process used to pre-screen residents and identify people with mental illness, intellectual disability, or developmental disability to determine whether required services are needed. Resident #67 was admitted with chronic lung disease and later had diagnoses added including Adjustment Disorder with Depressed Mood, Insomnia, and Anxiety Disorder. The PASARR dated 11/3/2024 listed depression as mild or situational and showed a Level I negative outcome, but there was no documentation that a PASARR was submitted for Level II evaluation after the new mental health diagnoses were added. Resident #33 was admitted with dementia, history of alcoholism, anxiety, depression, and insomnia, and later had PTSD added on 9/20/2024 and hallucinations added on 4/8/2025. Earlier PASARRs showed history of alcoholism and later dementia and anxiety disorder with no Level II evaluation required, but there was no documentation that a new PASARR was submitted after depression and insomnia were identified on admission or after PTSD and hallucinations were added. The DON confirmed on interview that PASARRs had not been submitted to the state-designated authority for either resident after the new mental health diagnoses were identified.
Expired and Undated Medications Stored for Resident Use
Penalty
Summary
The facility failed to properly store medications and biologicals in 1 of 2 medication rooms reviewed. During observation of the [NAME] Unit 500 Medication Storage Room, surveyors found one FluAd influenza vaccine 0.5 ml pre-filled syringe in the medication refrigerator with an expiration date of 5/20/2025 and available for resident use. In the same room, an opened 30 ml multi-dose vial of TB ppd was 3/4 full but did not have a date showing when it had been opened, and the LPN confirmed the vial was undated and could not provide an opened date. Surveyors also observed multiple expired items in the medication storage room, including 8 Vacuette blue top 3.5 mL vials expired 10/31/2024, 1 povidone-iodine swab expired 4/2025, 2 tubes of bacitracin ointment expired 6/2025, 2 enteral distal end En-fit transition connectors with cap expired 4/18/2025, and 48 No-Sting skin prep wipes expired 10/1/2024. The LPN confirmed these expired medications and items were available for resident use. The DON later confirmed TB ppd vials should be dated when opened and discarded within 30 days, and confirmed the expired medications and items should have been discarded.
Failure to Perform Hand Hygiene During Meal Tray Service
Penalty
Summary
The facility failed to provide and implement its infection prevention and control program during lunch meal service when staff did not offer hand hygiene assistance to residents before meals and did not perform hand hygiene between serving meal trays. Facility policy stated that staff assigned to passing meal trays would practice proper hand hygiene between each resident served, and the hand hygiene policy identified hand hygiene as the primary means to prevent the spread of infections and directed staff to use alcohol-based hand rub or soap and water before and after assisting a resident with meals. During observations on the lunch meal rounds, CNA C delivered trays to Resident #6, Resident #63, Resident #43, and Resident #44, set up the trays, and exited the rooms without performing hand hygiene between residents. CNA D delivered trays to Resident #16 and Resident #77 and also failed to offer hand hygiene assistance before serving the meal trays. The observations showed that hand hygiene was not performed as required during tray delivery on two of four hallways observed. The residents involved had diagnoses and care needs that included dementia, diabetes, heart failure, Parkinson's disease, end stage renal disease, muscle weakness, difficulty walking, and anxiety disorder. Several residents had cognitive impairment, and the records showed they required varying levels of assistance with eating and personal hygiene. The CNA staff confirmed during interview that hand hygiene had not been offered to Resident #6 and had not been performed while passing trays to Resident #63, #43, and #44, and CNA D confirmed hand hygiene had not been offered to Resident #16 and #77. The DON later confirmed staff should offer residents hand hygiene before serving meal trays and should perform hand hygiene after serving each meal tray.
Failure to Post Accurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the Benefits Improvement and Protection Act (BIPA) staffing posting requirements by not posting accurate and current daily nurse staffing information. The facility's policy mandates that Skilled Nursing Facilities (SNFs) must post the specific shift schedule and the number and category of nursing staff employed or contracted for each 24-hour period, including the total number of hours worked by licensed nursing staff. However, during an observation on May 13, 2024, it was found that the staffing information posted was outdated, reflecting staffing for April 26, 2024, instead of the current date. Additionally, the facility's daily nurse staff posting sheets lacked documentation of Registered Nurse (RN) hours for several dates, despite records showing that RN E worked specific hours on those days. The Director of Nursing (DON) confirmed the oversight in updating the staffing sheets and the omission of RN hours documentation.
Improper Sealing of Food Items
Penalty
Summary
The facility failed to ensure proper sealing of food items, which could potentially affect 69 out of 70 residents. The facility's policy, dated June 4, 2021, requires that spice jars be closed when not in use and that opened food be transferred to an airtight container or zip lock bag. During an observation of the food preparation room, conducted with the Dietary Manager, it was found that a 16-ounce bottle of garlic powder, a 19-ounce bottle of onion powder, and a 42-ounce box of quick oats were not sealed and were open to air. In an interview, the Dietary Manager confirmed that dry cereal and dried seasoning should be fully sealed after use and acknowledged that the food items had not been stored properly.
Failure to Conduct Level 2 PASRR Evaluation
Penalty
Summary
The facility failed to identify and refer a resident for a Level 2 PASRR evaluation, which is required for individuals with certain mental health conditions. The resident in question was admitted with diagnoses including Post Traumatic Stress Disorder (PTSD), Anxiety, Adjustment Disorder with Depression, and Insomnia. However, the PASRR Level 1 form completed prior to admission incorrectly indicated that no mental health diagnosis was known or suspected. A subsequent psychiatric evaluation confirmed the presence of these mental health conditions. During an interview, the Human Resource Manager acknowledged that the PASRR was completed at the hospital before admission and confirmed the oversight in not referring the resident for a Level 2 evaluation to determine the need for specialized services.
Failure to Update Care Plan for Dialysis Treatment Frequency
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident who was admitted with diagnoses including Chronic Kidney Disease, Congestive Heart Failure, and Diabetes. The resident's care plan, dated December 29, 2023, indicated a potential for complications related to hemodialysis, with scheduled treatments three times a week. However, during an interview on May 14, 2024, the resident reported that their dialysis treatments had been reduced to twice a week. This change was confirmed by the Director of Nursing, who acknowledged that the care plan had not been updated to reflect the reduced frequency of dialysis treatments, despite the change occurring some time ago.
Improper Garbage and Refuse Containment
Penalty
Summary
The facility failed to ensure proper containment of garbage and refuse in two dumpsters, identified as Dumpster A and B. According to the facility's policy on trash disposal, dated February 27, 2020, trash should be disposed of appropriately, and the dumpster area should be maintained for cleanliness and prevention of rodents, with lids closed and no trash on the ground. However, during an observation on May 13, 2024, at 10:40 AM, it was noted that the entry doors on both sides of Dumpster A and B were open. The area surrounding these dumpsters was littered with multiple disposable gloves, two broken office chairs, and two ripped mattresses. This observation was confirmed by the Dietary Manager during an interview at 10:50 AM on the same day, acknowledging that the dumpster area had not been maintained in a sanitary condition. The deficiency highlights a failure to adhere to the facility's established trash disposal policy, resulting in unsanitary conditions around the dumpsters. The presence of open dumpster doors and scattered refuse, including gloves, chairs, and mattresses, indicates a lack of proper waste management and containment, as required by the facility's guidelines.
Failure to Update Physician Order for Dialysis Schedule
Penalty
Summary
The facility failed to obtain an updated physician order for a resident who was receiving dialysis treatments. The resident, who was admitted with diagnoses including Chronic Kidney Disease, Congestive Heart Failure, and Diabetes, initially had a physician's order for hemodialysis three times a week. However, during an interview, the resident stated that the doctor had changed her dialysis schedule to twice a week. A facility document confirmed this change, but the facility did not update the physician's order to reflect the new dialysis schedule. The Director of Nursing confirmed that the resident's dialysis treatments had been reduced to twice a week some time ago, but acknowledged that the facility had not obtained a new physician's order to document this change. This oversight was identified during a review of the resident's medical records and interviews conducted as part of the facility's policy review.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to adhere to infection control practices during medication administration for two residents. Resident #63, who was admitted with diagnoses including the need for personal assistance with personal care, obstructive and reflux uropathy, and elevated white blood cell count, was observed during a medication administration incident. RN A exited a resident's room without performing hand hygiene, donned gloves, and prepared medications for Resident #63. Despite a sign indicating enhanced barrier precautions, RN A entered the resident's room without removing the soiled gloves or sanitizing hands, which was confirmed during an interview. For Resident #35, who was admitted with chronic pain syndrome, legal blindness, weakness, and reduced mobility, RN A was observed sanitizing hands and preparing medications. However, RN A dropped an Oxycodone tablet on the medication cart surface, donned clean gloves, picked up the tablet, and placed it in a medication cup. The tablet, along with other medications, was administered to Resident #35, despite RN A confirming in an interview that the dropped medication should have been discarded. The Director of Nursing confirmed that RN A did not follow standard precautions and facility infection control practices during these incidents.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent physical abuse for a resident, identified as Resident #52, who was involved in an altercation with another resident, identified as Resident #272. Resident #52, who has moderate cognitive impairment, was admitted with diagnoses including Osteoarthritis, Polyneuropathy, and Anxiety. On the day of the incident, Resident #272, who has severe cognitive impairment and a history of aggressive behavior due to dementia, entered Resident #52's room multiple times, initially unclothed, and later attempted to physically assault Resident #52. The incident occurred when Resident #272 entered Resident #52's room and began hitting her. Despite the presence of Resident #52's daughter, who attempted to shield her mother, Resident #272 made contact with Resident #52's hands and stomach. The facility's staff, including an LPN and a CNA, intervened after hearing screams, and Resident #272 was removed from the room. The facility's investigation confirmed that Resident #272 hit Resident #52, although no injuries were observed. Interviews with the involved parties, including Resident #52, her daughter, the LPN, and the CNA, corroborated the sequence of events. The staff had previously redirected Resident #272 back to his room after finding him naked in Resident #52's room. However, Resident #272 returned and assaulted Resident #52. The Director of Nursing confirmed the incident and the findings of the investigation, which highlighted the facility's failure to prevent the abuse despite having policies in place to create a resident-sensitive and secure environment.
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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 Sweetwater
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wood Village | 2 mi | ★★★★★ | 0 | 0 |
| Monroe Health And Rehabilitation Center | 8.1 mi | ★★★★★ | 18 | 0 |
| Life Care Center Of Athens | 11.3 mi | ★★★★★ | 12 | 1 |
| Nhc Healthcare, Athens | 11.7 mi | ★★★★★ | 0 | 0 |
| River Grove Health And Rehabilitation | 13.3 mi | ★★★★★ | 12 | 0 |
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