The Waters of Cheatham, LLC

Inspectors wroteBased on policy review, Centers for Medicare & Medicaid Services guidelines, Infection Prevention Control Officer Training certificate review, and interview, the facility failed to ensure employment of a qualified Infection Control Preventionist to monitor and maintain the facility's Infection Prevention and Control Program. This could have affected 54 out of 54 residents residing in the facility.

Inspectors wroteBased on policy review, medical record review, observation, and interview the facility failed to ensure wound assessments and treatments were completed correctly as ordered by the physician for 2 of 4 (Resident #8 and #51) sampled residents reviewed for pressure ulcers/wounds.

Inspectors wroteBased on Quarterly Payroll Based Journal (PBJ) review, facility staffing information review, and interview, the facility failed to submit accurate staffing data for Quarter 1 for PBJ 2026 (October 1, 2025- December 31, 2025) reviewed for staffing data.

Inspectors wroteBased on facility policy review, review of the Administrator's Job Description, review of the TELS (telephone communication system designed for healthcare environments to handle maintenance) work orders, Previous Maintenance Director employee file, medical record review, observations and interviews, the facility failed to provide a safe, clean, comfortable and homelike environment for 2 of 8 (400 Hall women's communal bathroom and 400 Hall men's communal bathroom) communal bathrooms observed.

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to provide an ongoing program of activities designed to meet the interests, physical, mental, and psychosocial well-being for 7 of 10 sampled residents (Resident #5, #9, #22, #26, #29, #41, and #54) reviewed for activities.

Inspectors wroteBased on facility policy review, observations and interviews, the facility failed to ensure nurse staffing information for licensed and unlicensed staff responsible for resident care was posted daily for 3 of 3 (3/23/2026, 3/24/2026, and 3/25/2026) days reviewed.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to maintain or enhance residents' dignity and respect when 4 of 7 staff members (Certified Nursing Assistant (CNA) #1, #2, and #4, and Licensed Practical Nurse (LPN) #3) failed to use courtesy titles, stood over a resident when assisting with a meal, and failed to knock when entering the residents' rooms for 14 of 64 residents (Resident #3, #7, #12, #17, #18, #20, #23, #29, #31, #33, #34, #40, #56, and #214) observed.

Inspectors wroteBased on policy review, medical record review, and interview the facility failed to ensure 5 of 16 sampled residents (Resident #29, #49, #52, #56, and #60) or their families were invited to participate in planning their care.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when medications were found unsecured and not attended by authorized staff, open, undated, and expired in 4 of 9 medication storage areas (100 Hall Medication Cart, 300 Hall Medication Cart, 200 Hall Medication Cart, and 100/200 Hall Medication Room) reviewed.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when 3 of 7 staff members (Certified Nursing Assistant (CNA) #1, CNA #5, and CNA #6) failed to perform proper hand hygiene for 13 of 64 residents (Resident #7, #12, #15, #17, #37, #40, #43, #47, #49, #51, #56, #57, and #59) observed during meal service.

Inspectors wroteBased on Centers for Disease Control (CDC) guidelines, policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 7 staff members (Certified Nursing Assistant (CNA) #1) observed failed to properly don (to put on) Personal Protective Equipment (PPE) for 3 of 64 residents (Resident #40, #37, and #43) observed during dining; when 1 of 3 staff members (Licensed Practical Nurses (LPN) #2) failed to clean nebulizer equipment and a reusable syringe properly for Resident #22 and #54 during medication administration; when 1 of 1 staff member (CNA #2) was observed entering a Transmission Based Precautions (TBP) room without the proper PPE; when the facility failed to ensure continuous TBP status for 1 of 2 sampled residents (Resident #60) in TBP; [...]

Inspectors wroteBased on policy review, employee personnel file review, and interview, the facility failed to ensure employees were screened for a history of abuse, neglect, and exploitation of resident property prior to being hired for 2 of 6 sampled employees (Director of Nursing (DON) and Dietary Aide #1) reviewed.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to permit a resident to return to the facility after a hospitalization for 1 of 2 residents (Resident #163) reviewed for hospitalization.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to develop a Baseline Care Plan within 48 hours of admission that included the initial goals and needs for 2 of 5 sampled residents (Resident #29 and #213) reviewed.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure residents were free from a significant medication error for 1 of 5 sampled residents (Resident #60) reviewed for medications. Resident #60 received her scheduled Insulin (a medication that lowers blood glucose levels) when her blood glucose was outside the ordered parameters.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 3 of 18 (Resident #42, #270 and #277) sampled residents were uncovered and exposed, and 5 of 15 (Certified Nursing Assistant (CNA) #1, #2, #3, #4, and #5) CNAs were observed standing to feed residents.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to monitor for behaviors for 3 of 5 (Resident #12, #16, and #67) sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on medical record review and interview, the facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for 1 of 18 (Resident #58) sampled residents reviewed.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure assessments were accurate for 1 of 21 (Resident #71) sampled residents reviewed.

Inspectors wroteBased medical record review and interview, the facility failed to provide Activities of Daily Living (ADLs) for 1 of 4 (Resident #6) sampled resident reviewed for ADLs.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to provide individualized activities of interest for 1 of 1 (Resident #40) sampled residents reviewed for Activities.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure physician orders were followed for 3 of 18 (Resident #3, #12, and #53) sampled residents reviewed.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure accurate documentation related to Advanced Directives for 1 of 24 (Resident #58) sampled residents reviewed.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 1 (Certified Nursing Assistant (CNA) #2) CNAs failed to dispose of a soiled brief and bedpan contents properly during toileting care and when 2 of 2 (Licensed Practical Nurse (LPN) #2 and Registered Nurse (RN) #1) nurses failed to maintain wound asepsis during wound care.