Inspection Reports for Alpha Home – a Waters Community
2640 COLD SPRING RD, IN, 46222
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Re-Inspection
Census: 51
Capacity: 51
Deficiencies: 0
Jun 26, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00459052 completed on May 28, 2025.
Findings
Alpha Home - A Waters Community was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaint IN00459052.
Complaint Details
Complaint IN00459052 - Corrected.
Report Facts
Census Bed Type: 51
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 37
Census Payor Type - Other: 12
Inspection Report
Complaint Investigation
Census: 50
Capacity: 50
Deficiencies: 3
May 28, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00459052, which involved federal and state deficiencies related to allegations concerning pressure ulcer care and fall prevention.
Findings
The facility failed to prevent the development and worsening of a pressure ulcer in Resident B, which resulted in hospitalization and wound debridement. Additionally, the facility failed to ensure individualized fall prevention interventions and follow-up assessments were completed for Resident B after a fall. Medication storage deficiencies were also noted.
Complaint Details
Complaint IN00459052 involved allegations related to pressure ulcer care and fall prevention. The complaint was substantiated with federal and state deficiencies cited at F686 and F689.
Severity Breakdown
SS=G: 1
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to prevent development of a stage II pressure ulcer that progressed to an unstageable wound resulting in actual harm requiring hospitalization and wound debridement. | SS=G |
| Failed to ensure fall prevention interventions were individualized and implemented, and fall follow-up assessments were completed for Resident B after a fall. | SS=D |
| Failed to ensure medication and biologicals were stored according to facility policy; treatment cart was left unlocked and unattended with medications accessible. | SS=D |
Report Facts
Census: 50
Total Capacity: 50
Deficiencies cited: 3
Fall Intervention Audit Frequency: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Reed | Administrator | Signed the inspection report |
| Wound NP 5 | Nurse Practitioner who assessed Resident B's pressure ulcer and recommended interventions | |
| Regional Nurse Consultant | Provided policy information and reviewed Resident B's clinical record | |
| Licensed Practical Nurse 6 | LPN | Provided information about Resident B's care and fall follow-up documentation |
| Certified Nursing Aide 11 | CNA | Witnessed Resident B's fall and provided care at the time |
| Licensed Practical Nurse 7 | LPN | Observed unlocked treatment cart and secured it |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 57
Deficiencies: 0
Mar 12, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00449638, IN00453113, IN00453236, and IN00454453 at Alpha Home - A Waters Community.
Findings
No deficiencies related to the allegations in any of the four complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigations.
Complaint Details
Complaints IN00449638, IN00453113, IN00453236, and IN00454453 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 57
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 39
Census Payor Type - Other: 16
Total Census: 57
Inspection Report
Life Safety
Deficiencies: 0
Dec 13, 2024
Visit Reason
The visit was conducted as a Post Survey Revisit (PSR) for the Life Safety Code Recertification and State Licensure Survey that previously exited on 10/21/24.
Findings
Alpha Home - a Waters Community was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Re-Inspection
Census: 60
Capacity: 86
Deficiencies: 2
Dec 5, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 10/21/2024 was performed to verify correction of previously cited deficiencies.
Findings
The facility was found not in compliance with Life Safety Code requirements related to corridor door latching and ground fault circuit interrupter (GFCI) protection in restrooms. Repairs were made and systemic corrective actions were implemented to prevent recurrence, with compliance achieved by 12/11/2024.
Severity Breakdown
SS=E: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure 1 of over 50 corridor doors had no impediment to closing and latching into the door frame and would resist the passage of smoke. | SS=E |
| Failed to ensure all restrooms were provided with ground fault circuit interrupter (GFCI) protection against electric shock; one GFCI receptacle failed to function properly. | SS=D |
Report Facts
Facility capacity: 86
Census: 60
Number of corridor doors inspected: 50
Number of residents potentially affected by door deficiency: 30
Number of residents potentially affected by GFCI deficiency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karl Eck | Laboratory Director or Provider/Supplier Representative | Signed the report |
| Director of Nursing | Interviewed regarding corridor door and GFCI deficiencies and confirmed issues | |
| Maintenance Supervisor | Performed repairs and inspections related to corridor doors and GFCI outlets | |
| Administrator | Verified repairs and monitored corrective action implementation |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 29, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00441434 completed on September 16, 2024.
Findings
Alpha Home - A Waters Community was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint.
Complaint Details
Investigation of Complaint IN00441434; paper compliance review completed and found in compliance.
Inspection Report
Life Safety
Census: 53
Capacity: 86
Deficiencies: 3
Oct 21, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness requirements but not in compliance with Life Safety Code requirements. Deficiencies included corridor doors that did not latch properly, non-functioning ground fault circuit interrupter (GFCI) receptacles in restrooms, and improper disposal of smoking materials in an outdoor area.
Severity Breakdown
SS=E: 1
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Two corridor doors to resident rooms 305 and 214 would not latch into their frames and resist passage of smoke. | SS=E |
| One electric receptacle within two feet of the sink in the restroom located in resident room 111 had a GFCI that failed to function properly. | SS=D |
| Smoking materials were not deposited into ashtrays and metal containers with self-closing cover devices in one outdoor area where smoking was taking place. | SS=D |
Report Facts
Certified beds: 86
Census: 53
Corridor doors inspected: 50
Residents potentially affected: 30
Cigarette butts found: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Duhaime | Interim ED | Signed the report |
| Maintenance Director | Interviewed and confirmed deficiencies related to corridor doors and GFCI receptacle | |
| Administrator | Reviewed findings and corrective actions at exit conference | |
| Maintenance Supervisor | Performed repairs and inspections related to corridor doors and GFCI receptacles | |
| Housekeeping Supervisor | Removed cigarette butts and involved in smoking area corrective actions |
Inspection Report
Annual Inspection
Census: 54
Capacity: 54
Deficiencies: 14
Sep 26, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from September 23 to 26, 2024.
Findings
The facility was found deficient in multiple areas including resident dignity, resident council grievance follow-up, MDS accuracy, comprehensive care plans, care plan revisions, quality of care related to falls, contracture prevention, medication management, radiology services, infection control, and vaccination administration.
Severity Breakdown
SS=D: 10
SS=E: 3
SS=G: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to ensure dignity for a female resident with long facial hair. | SS=D |
| Failed to ensure Resident Council grievances were followed up on and reported back to the Resident Council. | SS=E |
| Failed to accurately code the Minimum Data Set (MDS) for 5 residents. | SS=E |
| Failed to add comprehensive care plans for 2 residents. | SS=D |
| Failed to update care plans with changes in resident care for 2 residents. | SS=D |
| Failed to ensure a resident who experienced a fall was not moved until after a medical assessment was completed. | SS=D |
| Failed to ensure a resident received treatments and services to prevent worsening of contracture. | SS=D |
| Failed to prevent accidents when transportation staff were not trained on new bus equipment and failed to install a safety lap belt, resulting in actual harm. | SS=G |
| Failed to obtain a resident's blood pressure and pulse prior to administering metoprolol as ordered. | SS=D |
| Failed to ensure pharmacy recommendations to reduce psychotropic medications were declined with adequate documentation of symptoms for 2 residents. | SS=D |
| Failed to date medications when opened for medication and treatment carts. | SS=E |
| Failed to ensure an x-ray was completed as ordered for a resident. | SS=D |
| Failed to properly sanitize a blood glucometer stored on the treatment cart. | SS=D |
| Failed to ensure influenza vaccination was offered and pneumonia and COVID-19 vaccinations were completed for a resident who requested them. | SS=D |
Report Facts
Survey dates: 4
Census: 54
Total capacity: 54
Residents reviewed for MDS accuracy: 5
Residents reviewed for care plan revision: 3
Residents reviewed for medication: 6
Residents reviewed for vaccinations: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in multiple findings including dignity, MDS accuracy, care plan revisions, fall assessment, medication administration, x-ray follow-up, and infection control |
| Qualified Medication Assistant 16 | QMA | Preferred staff member for Resident 33's facial hair grooming |
| Qualified Medication Assistant 13 | QMA | Observed medication and treatment carts with undated medications |
| Regional Consultant 8 | Regional Consultant | Provided policy and interview regarding MDS accuracy and bus training |
| Bus Driver | Involved in fall incident of Resident 11 on bus | |
| Maintenance Director | Involved in fall incident of Resident 11 on bus |
Inspection Report
Renewal
Deficiencies: 0
Sep 26, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on September 26, 2024.
Findings
Alpha Home - A Waters Community was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 50
Capacity: 50
Deficiencies: 1
Sep 16, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00441434 regarding federal and state deficiencies related to tracheostomy care orders at the facility.
Findings
The facility failed to ensure that a resident with a tracheostomy had physician's orders for tracheostomy care, oxygen, oxygen humidity, suctioning, and oxygen saturation monitoring for approximately four months after admission. The resident's medical record lacked these orders until 7/11/24 despite admission on 6/26/24 and respiratory equipment setup on 6/25/24.
Complaint Details
Complaint IN00441434 was substantiated with federal and state deficiencies cited related to the allegations concerning lack of physician orders for tracheostomy care and related respiratory treatments.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident with a tracheostomy had physician's orders for tracheostomy care, oxygen, oxygen humidity, suctioning, and oxygen saturation monitoring. | SS=D |
Report Facts
Census: 50
Total Capacity: 50
Medicare Census: 6
Medicaid Census: 41
Other Payor Census: 3
Audit Frequency: 5
Audit Frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in relation to findings and corrective actions regarding tracheostomy care orders and education |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 55
Deficiencies: 0
Aug 12, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00439071.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00439071 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 55
Total Capacity: 55
Medicare Census: 2
Medicaid Census: 52
Other Payor Census: 1
Inspection Report
Complaint Investigation
Census: 54
Capacity: 54
Deficiencies: 0
Jul 17, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00437362.
Findings
No deficiencies related to the allegations in Complaint IN00437362 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00437362 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 54
Total Capacity: 54
Medicare Census: 6
Medicaid Census: 47
Other Payor Census: 1
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 0
May 31, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00435395.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00435395 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare residents: 3
Medicaid residents: 36
Other residents: 13
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 1
Jan 31, 2024
Visit Reason
The visit was conducted to investigate complaints IN00416811, IN00417628, and IN00419803 concerning allegations of misappropriation of resident property.
Findings
The facility failed to protect a resident's debit card from diversion, resulting in $15,179.18 being spent by an employee without the resident's knowledge. The deficient practice was corrected prior to the survey and was therefore past noncompliance. The facility implemented systemic corrective actions including staff education, audits, offering lock boxes and RFMS accounts to residents, and ongoing monitoring through QAPI.
Complaint Details
Complaints IN00416811 and IN00417628 were substantiated with federal/state deficiencies cited at F602. Complaint IN00419803 was not substantiated with no deficiencies cited.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident debit card was protected from diversion, resulting in unauthorized spending of $15,179.18 by an employee. | SS=D |
Report Facts
Amount misappropriated: 15179.18
Number of residents reviewed for misappropriation: 4
Number of transactions: 22
Number of cash withdrawals: 18
Census: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| ADM 12 | Facility Administrator | Admitted to withdrawing money from resident's debit card without consent; employment separated. |
| BOM 13 | Business Office Manager | Disclosed suspicious activity on resident's debit card and was suspended during investigation. |
| RDO | Regional Director of Operations | Conducted investigation, notified police and Attorney General's office, and provided policy information. |
Inspection Report
Follow-Up
Census: 56
Capacity: 86
Deficiencies: 0
Oct 25, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 08/30/2023.
Findings
At the Emergency Preparedness survey, the facility was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. At the Life Safety Code survey, the facility was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code.
Report Facts
Certified beds: 86
Census: 56
Inspection Report
Life Safety
Census: 58
Capacity: 86
Deficiencies: 8
Aug 30, 2023
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health to assess compliance with Medicare/Medicaid requirements and Life Safety Code standards.
Findings
The facility was found not in compliance with emergency preparedness testing requirements, emergency power system maintenance, means of egress, fire drills, smoking regulations, fire door inspections, and gas equipment storage and securing. Several deficiencies were identified including failure to conduct required emergency preparedness exercises, incomplete generator testing records, malfunctioning corridor doors, missing fire drills, improper cigarette butt disposal, incomplete fire door inspections, and unsecured oxygen cylinders.
Severity Breakdown
SS=C: 1
SS=E: 4
SS=F: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to conduct exercises to test the emergency plan at least twice per year including unannounced staff drills. | SS=C |
| Failed to implement emergency power system inspection, testing, and maintenance requirements; missing weekly generator testing records for several weeks. | SS=F |
| Barrier door set on the 100 hall did not open properly, impeding means of egress. | SS=E |
| Failed to conduct quarterly fire drills for one quarter on the day shift. | SS=F |
| Main entrance area had over 50 cigarette butts on the ground with no approved container for disposal; employees were smoking outside the main entrance not in designated area. | SS=E |
| Failed to ensure annual inspection and testing of all fire door assemblies including the door to the oxygen transfilling room. | SS=E |
| Failed to maintain written records of weekly generator inspections for 3 of 52 weeks. | SS=F |
| Failed to properly secure two portable oxygen cylinders in the oxygen storage and transfilling room. | SS=E |
Report Facts
Certified beds: 86
Census: 58
Missing weekly generator tests: 3
Cigarette butts counted: 50
Fire drills missing: 1
Oxygen cylinders unsecured: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Mentioned in relation to emergency preparedness exercises, generator testing, door repairs, and smoking area observations | |
| Administrator | Mentioned in exit conferences and corrective action oversight | |
| Maintenance Supervisor/Designee | Responsible for conducting drills, inspections, and corrective actions | |
| Director of Nursing | Involved in securing oxygen cylinders and corrective actions | |
| Housekeeping Supervisor/Designee | Involved in cigarette butt cleanup and inspections |
Inspection Report
Annual Inspection
Census: 56
Capacity: 56
Deficiencies: 10
Aug 11, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00411354.
Findings
The facility was found deficient in multiple areas including call light accessibility, advanced directive orders, safe and home-like environment, accuracy of assessments, smoking policy compliance, nutrition and hydration, respiratory care, and dementia care activities.
Complaint Details
Complaint IN00411354 was investigated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=E: 2
SS=D: 6
SS=B: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure call light was within reach of Resident 26 who was able to use it independently. | SS=D |
| Failed to ensure residents had orders for advance directives; Resident 29 lacked an order until corrected. | SS=D |
| Failed to provide a safe, clean, comfortable, home-like environment; Resident 26's room contained an unmade, dirty mattress and clutter. | SS=D |
| Failed to accurately update Minimum Data Set (MDS) assessments for amputations, hospice status, anticoagulant use, and Level II assessments for multiple residents. | SS=B |
| Failed to revise care plan for Resident 31 who did not smoke, but care plan indicated smoker. | SS=D |
| Failed to ensure residents did not keep smoking materials independently against facility policy and without appropriate assessment or monitoring for 9 residents. | SS=E |
| Failed to provide prescribed diet, weekly weights as ordered, and alternative snacks/hydration during scheduled snack activities for Resident 44. | SS=D |
| Failed to ensure respiratory equipment was properly replaced, stored, and cleaned for residents using respiratory care; failed to keep ambu-bag accessible for Resident 26. | SS=E |
| Failed to provide alternative or adaptive activities for Resident 40 with dementia who was NPO and unable to participate in scheduled activities. | SS=D |
| Failed to ensure Resident 3 received thickened liquids as ordered; regular water was found in her room instead of nectar thickened liquids. | SS=D |
Report Facts
Deficiencies cited: 10
Residents reviewed for call light: 9
Residents reviewed for MDS accuracy: 8
Residents reviewed for accidents: 9
Residents reviewed for hydration/nutrition: 2
Residents reviewed for respiratory care: 4
Residents reviewed for dementia care: 2
Residents reviewed for thickened liquids: 7
Inspection Report
Renewal
Deficiencies: 0
Aug 11, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on August 11, 2023.
Findings
Alpha Home - A Waters Community was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 0
Jun 15, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00407897 and IN00410268.
Findings
No deficiencies related to the allegations in complaints IN00407897 and IN00410268 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00407897 - No deficiencies related to the allegations are cited. Complaint IN00410268 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type: 61
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 41
Census Payor Type - Other: 10
Inspection Report
Complaint Investigation
Census: 59
Capacity: 59
Deficiencies: 0
Mar 23, 2023
Visit Reason
This visit was for the investigation of complaints IN00396344, IN00397054, and IN00397818.
Findings
No deficiencies related to the allegations were cited for any of the three complaints investigated. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaints IN00396344, IN00397054, and IN00397818 were investigated and no deficiencies related to the allegations were cited.
Report Facts
Census: 59
Total Capacity: 59
Medicare Census: 6
Medicaid Census: 37
Other Payor Census: 16
Inspection Report
Complaint Investigation
Census: 61
Capacity: 61
Deficiencies: 0
Oct 31, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00385839.
Findings
The complaint IN00385839 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with applicable regulations regarding the complaint.
Complaint Details
Complaint IN00385839 was investigated and determined to be unsubstantiated due to lack of evidence.
Report Facts
Census: 61
Total Capacity: 61
Medicare Census: 3
Medicaid Census: 45
Other Payor Census: 13
Inspection Report
Re-Inspection
Census: 52
Capacity: 52
Deficiencies: 0
Aug 2, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on June 7, 2022.
Findings
Alpha Home - A Waters Community was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census: 52
Total Capacity: 52
Medicare Census: 8
Medicaid Census: 33
Other Payor Census: 11
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