The Waters of Cheatham, LLC

In the surveyor’s words

From the most serious findings on record at The Waters of Cheatham, LLC, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF882Mar 26, 2026

  Based 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. The findings include: 1. Review of the undated facility policy titled, Infection Prevention and Control-Policy and Procedure (IPCP), revealed .It is the policy of the facility to ensure that a comprehensive system is in place that prevents, identifies, investigates reports, records, and controls infections and prevent the development and transmission of communicable disease processes for… […]

• No harm, potential for more than minimal, patternF686Mar 26, 2026

  Based 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. The findings include: 1.Review of the facility's policy titled GUIDELINES FOR PREVENTION / TREATMENT OF PRESSURE INJURIES . dated 10/9/2023, revealed .It is the intent of the facility to recognize the following information and to act on it in such a way as to practice evidence-based recommendations for the prevention/treatment of pressure injuries to the residents who reside in the facility .A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice,… […]

• No harm, potential for more than minimal, patternF851Mar 26, 2026

  Based 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. The findings include: 1. Review of the Centers for Medicare & [and] Medicaid Services Electronic Staffing Data Submission Payroll-Based Journal Long-Term Care Facility Policy Manual dated June 2025, revealed . Direct care staffing and census data will be collected quarterly, and is required to be timely and accurate. 2. Review of the PBJ (Payroll-Based Journal) Staffing Data Report for Quarter 1 of 2026 (October 1, 2025 - December 31, 2025) revealed excessively low weekend staffing. 3. […]

• No harm, potential for more than minimal, patternF550Apr 27, 2022

  Based 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. The findings include: Review of the facility's undated policy titled, Dignity, revealed .Staff will be polite and respectful at all times .When addressing a resident, staff will refrain from calling the resident names like .Sweetie .Honey .as this can be interpreted as undignified . […]

• No harm, potential for more than minimal, patternF553Apr 27, 2022

  Based 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. The findings include: Review of the facility's policy titled Baseline Care Plan Assessment/Comprehensive Care Plans, dated 11/25/2017, revealed .Social Service Director .will notify the resident's responsible party either by letter or phone call to inform them of the scheduled Care Plan Conference to include the date and time. This notification will continue for subsequent Care Plan Conferences. […]