The Waters of Johnson City, LLC

In the surveyor’s words

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

• No harm, potential for more than minimal, isolatedF695Aug 19, 2026

  Based on facility policy review, medical record review, observation, and interview, the facility failed to perform tracheostomy (trach) (a surgically created opening in the front of the neck leading to the windpipe/trachea for breathing) care to maintain infection control practices during trach care for 1 resident (Resident #11) of 1 resident reviewed for tracheostomies and the facility failed to ensure oxygen was administered according to Physician's Orders for 1 resident (Residents #25) of 10 residents reviewed for oxygen (O2) therapy. […]

• No harm, potential for more than minimal, isolatedF761Aug 19, 2026

  Based on facility policy review, observations, and interviews, the facility failed to ensure medications were securely stored in 1 medication cart of 4 medication carts observed, the facility failed to ensure expired over the counter (OTC) medications were disposed of and not available for resident use in 1 of 4 medication carts observed, and the facility failed to ensure expired laboratory blood collection tubes were disposed of and not available for resident use in 1 of 2 medication rooms observed. […]

• No harm, potential for more than minimal, isolatedF919Aug 19, 2026

  Based on facility policy review, medical record review, observations, and interviews the facility failed to ensure the call light was within reach for 3 residents (Resident #51, Resident #72, and Resident #55) of 73 residents observed. The findings include: Review of the facility's policy titled, Use of Call Light, dated 2006, revealed .be sure to position the call light conveniently for the resident to use .Tell the resident where the call light is .Ensure resident's call light is placed securely on the bed and remains within resident's reach . Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including Dementia, Diabetes Mellitus, and Heart Failure. […]

• No harm, potential for more than minimal, isolatedF644Feb 25, 2025

  Based on facility policy review, medical record review, and interview, the facility failed to resubmit a Pre-Admission Screening and Resident Review (PASARR) timely after a new mental health diagnosis for 2 residents (Resident #30, and Resident #14) of 6 residents reviewed for PASARR. The findings include: Review of the facility's policy titled, Guidelines For PASRR Process, dated 517/2023, revealed .PASRR [PASARR] is a federally mandated process that requires all states to pre-screen all residents regardless of their payer source or age who are seeking admission to a Medicaid funded nursing facility .PASRR has 3 goals: 1. Identify people, including adults, (residents), with mental illness .2. To ensure appropriate placement, whether in the community or in the nursing facility .3. […]

• No harm, potential for more than minimal, isolatedF656Feb 25, 2025

  Based on facility policy review, medical record review, observations, and interviews, the facility failed to develop a care plan for 1 resident (Resident #9) and failed to implement a care plan for 2 residents (Residents #32 and #38) for Enhanced Barrier Precautions (EBP) of 19 residents reviewed for care plans. The findings include: Review of the facility's policy titled, Baseline Care Plan Assessment/Comprehensive Care Plans, updated 9/18/2018, revealed .It is the policy of the facility to ensure .every resident has a .Care Plan completed and implemented .to promote continuity of care .communication among .staff .increase resident safety .to meet the resident's medical .nursing needs .develop .objectives along with appropriate interventions .to achieve .greatest degree of .safety . […]