Inspection Reports for
Alpha Home – a Waters Community
2640 COLD SPRING RD, INDIANAPOLIS, IN, 46222
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
20.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
383% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Dec 5, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care, including resident rights, use of restraints, medication management, activities, dialysis care, and laboratory services.
Findings
The facility was found deficient in multiple areas including failure to respond to Resident Council concerns, improper use of physical restraints, inadequate medication reconciliation at discharge, inaccurate resident assessments, incomplete PASRR screenings, insufficient assistance with activities of daily living, inadequate and poorly supervised activity programming especially for residents with dementia, lack of communication with dialysis centers, failure to provide individualized dementia care, and failure to obtain required laboratory cultures after a resident fall.
Deficiencies (10)
F 0565: The facility failed to provide documented responses or resolutions to recurring Resident Council concerns related to maintenance, nursing, dietary, and activities, affecting residents' quality of life.
F 0604: The facility used physical restraints by placing a resident in a heavy chair wedged under a table without physician orders or care plans, restricting movement and causing frustration.
F 0628: The facility failed to properly reconcile medications for a resident discharged home, lacking documentation of medication reconciliation.
F 0641: The facility failed to code residents' Minimum Data Set assessments accurately for medications, affecting 3 of 5 residents reviewed.
F 0645: The facility failed to complete a new PASRR level of care assessment after the 30-day exemption expired for a resident.
F 0677: The facility failed to ensure a resident was clean, appropriately dressed, and had bedding changed when soiled, with repeated refusals of showers undocumented and unaddressed.
F 0679: The facility failed to provide scheduled activities, adequate staff engagement, and individualized dementia programming, leaving residents unoccupied and frustrated.
F 0698: The facility failed to ensure consistent communication between the facility and dialysis centers for residents receiving dialysis treatments.
F 0744: The facility failed to provide individualized, person-centered dementia care, relying on restraint-like practices and PRN medications without documented nonpharmacological interventions.
F 0772: The facility failed to obtain a urine culture and sensitivity after a resident was found on the floor, despite recommendations and lab orders.
Report Facts
Residents affected: 5
Residents affected: 1
Residents reviewed: 3
Residents reviewed: 5
Residents reviewed: 5
Residents reviewed: 1
Residents affected: 21
Residents reviewed: 2
Residents affected: 21
Residents reviewed: 3
Inspection Report
Re-Inspection
Census: 51
Capacity: 51
Deficiencies: 0
Date: Jun 26, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00459052 completed on May 28, 2025.
Complaint Details
Complaint IN00459052 - Corrected.
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.
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
Deficiencies: 3
Date: May 28, 2025
Visit Reason
The inspection was conducted in response to a complaint regarding inadequate pressure ulcer care and fall prevention for Resident B at the facility.
Complaint Details
The complaint involved concerns about Resident B's pressure ulcer care and a fall incident where Resident B fell out of bed while being cared for by a newly hired aide. The complaint also questioned staff qualifications and care adequacy.
Findings
The facility failed to prevent the development and worsening of a pressure ulcer in Resident B, resulting in actual harm and hospitalization. Additionally, the facility failed to implement individualized fall prevention interventions and complete required fall follow-up assessments after Resident B fell out of bed. Medication storage was also found to be unsecured.
Deficiencies (3)
F 0686: The facility failed to prevent a stage II pressure ulcer from progressing to an unstageable wound in Resident B, resulting in actual harm and hospitalization. Preventative skin care measures and documentation were inadequate.
F 0689: The facility failed to ensure individualized fall prevention interventions and complete fall follow-up assessments for Resident B after a fall out of bed. The care plan was not updated post-fall.
F 0761: The facility failed to ensure medication and biologicals were stored securely, as an unlocked treatment cart with medications was left unattended near residents.
Report Facts
Wound measurements: 10
Wound measurements: 5.5
Wound measurements: 2
Wound measurements: 7.5
Wound measurements: 5
Wound measurements: 3.5
Fall incident time: 5.5
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 6 | Licensed Practical Nurse | Provided information on Resident B's care and fall follow-up documentation |
| Licensed Practical Nurse 7 | Licensed Practical Nurse | Observed and secured unlocked treatment cart containing medications |
| Wound NP 5 | Wound Nurse Practitioner | Assessed Resident B's pressure ulcer and recommended treatment changes |
| Director of Nursing | Director of Nursing | Provided information on fall incident and care plan responsibilities |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 50
Deficiencies: 3
Date: 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.
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.
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.
Deficiencies (3)
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.
Failed to ensure fall prevention interventions were individualized and implemented, and fall follow-up assessments were completed for Resident B after a fall.
Failed to ensure medication and biologicals were stored according to facility policy; treatment cart was left unlocked and unattended with medications accessible.
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
Date: 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.
Complaint Details
Complaints IN00449638, IN00453113, IN00453236, and IN00454453 were investigated and found to have no deficiencies related to the allegations.
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.
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
Date: 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
Date: 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.
Deficiencies (2)
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.
Failed to ensure all restrooms were provided with ground fault circuit interrupter (GFCI) protection against electric shock; one GFCI receptacle failed to function properly.
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
Date: Oct 29, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00441434 completed on September 16, 2024.
Complaint Details
Investigation of Complaint IN00441434; paper compliance review completed and found in compliance.
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.
Inspection Report
Life Safety
Census: 53
Capacity: 86
Deficiencies: 3
Date: 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.
Deficiencies (3)
Two corridor doors to resident rooms 305 and 214 would not latch into their frames and resist passage of smoke.
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.
Smoking materials were not deposited into ashtrays and metal containers with self-closing cover devices in one outdoor area where smoking was taking place.
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
Routine
Deficiencies: 14
Date: Sep 26, 2024
Visit Reason
Routine inspection of Alpha Home - A Waters Community nursing facility to assess compliance with regulatory requirements including resident care, medication management, safety, and infection control.
Findings
The facility had multiple deficiencies including failure to ensure resident dignity, incomplete follow-up on Resident Council grievances, inaccurate Minimum Data Set (MDS) coding, incomplete care plans, failure to properly assess and manage resident falls, inadequate range of motion treatments, improper medication administration, failure to implement psychotropic medication reductions, improper medication labeling, delayed x-ray services, improper sanitization of glucometer, and incomplete vaccination administration.
Deficiencies (14)
F 0550: The facility failed to ensure dignity for a female resident with long facial hair who requested shaving assistance but was delayed until a preferred staff member was available.
F 0565: The facility failed to ensure Resident Council grievances were followed up on and reported back to the council for review and approval.
F 0641: The facility failed to accurately code the Minimum Data Set (MDS) for 5 residents, including incorrect anticoagulant and antiplatelet medication coding.
F 0656: The facility failed to add comprehensive care plans addressing nutritional needs and sleep difficulties for 2 residents.
F 0657: The facility failed to update care plans with changes in resident care for 2 residents, including refusal of medication dose reductions and antidepressant use.
F 0684: The facility failed to ensure a resident who fell on a bus was not moved until after medical assessment, risking worsening injuries.
F 0688: The facility failed to provide treatments and services to prevent worsening contracture in a resident's hand and wrist, including lack of passive range of motion and palm protector use.
F 0689: The facility failed to prevent accidents by not training transportation staff on new bus equipment and failing to install a safety lap belt, resulting in a resident fall and vertebra fracture.
F 0757: The facility failed to obtain a resident's blood pressure and pulse prior to administering metoprolol as ordered.
F 0758: The facility failed to ensure pharmacy recommendations for gradual dose reductions of psychotropic medications were declined with adequate documentation of symptoms for 2 residents.
F 0761: The facility failed to date medications when opened for 1 medication cart and 1 treatment cart.
F 0776: The facility failed to ensure an x-ray was completed timely for a resident with foot pain as ordered.
F 0880: The facility failed to properly sanitize a blood glucometer meter before use on a resident.
F 0883: The facility failed to ensure influenza vaccination was offered and pneumonia and COVID-19 vaccinations were completed for a resident who requested them.
Report Facts
Residents affected: 1
Residents affected: 4
Residents reviewed for MDS accuracy: 5
Residents reviewed for comprehensive care plans: 2
Residents reviewed for care plan revision: 3
Residents reviewed for falls: 2
Residents reviewed for medications: 6
Residents reviewed for unnecessary medications: 5
Medication carts reviewed: 3
Treatment carts reviewed: 3
Residents reviewed for x-rays: 1
Glucometer meters reviewed: 5
Residents reviewed for vaccinations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in multiple findings including resident dignity, MDS accuracy, fall investigation, medication administration, and infection control |
| Qualified Medication Assistant 16 | Qualified Medication Assistant | Preferred staff member for shaving Resident 33 |
| Qualified Medication Assistant 13 | Qualified Medication Assistant | Observed with medication and treatment carts lacking dates on opened medications |
| Bus Driver | Bus Driver | Involved in resident fall on bus and lacked proper training on bus equipment |
| Maintenance Director | Maintenance Director | Involved in resident fall on bus and lacked proper training on bus equipment |
Inspection Report
Annual Inspection
Census: 54
Capacity: 54
Deficiencies: 14
Date: 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.
Deficiencies (14)
Failed to ensure dignity for a female resident with long facial hair.
Failed to ensure Resident Council grievances were followed up on and reported back to the Resident Council.
Failed to accurately code the Minimum Data Set (MDS) for 5 residents.
Failed to add comprehensive care plans for 2 residents.
Failed to update care plans with changes in resident care for 2 residents.
Failed to ensure a resident who experienced a fall was not moved until after a medical assessment was completed.
Failed to ensure a resident received treatments and services to prevent worsening of contracture.
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.
Failed to obtain a resident's blood pressure and pulse prior to administering metoprolol as ordered.
Failed to ensure pharmacy recommendations to reduce psychotropic medications were declined with adequate documentation of symptoms for 2 residents.
Failed to date medications when opened for medication and treatment carts.
Failed to ensure an x-ray was completed as ordered for a resident.
Failed to properly sanitize a blood glucometer stored on the treatment cart.
Failed to ensure influenza vaccination was offered and pneumonia and COVID-19 vaccinations were completed for a resident who requested them.
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
Date: 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
Date: 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.
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.
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.
Deficiencies (1)
Failure to ensure a resident with a tracheostomy had physician's orders for tracheostomy care, oxygen, oxygen humidity, suctioning, and oxygen saturation monitoring.
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
Deficiencies: 1
Date: Sep 16, 2024
Visit Reason
The inspection was conducted in response to a complaint (IN00441434) regarding the facility's failure to provide safe and appropriate respiratory care for a resident with a tracheostomy.
Complaint Details
This citation relates to Complaint IN00441434.
Findings
The facility failed to ensure that Resident B had physician's orders for tracheostomy care, oxygen with humidity, suctioning, and oxygen saturation monitoring until 7/11/24, despite the resident's admission on 6/26/24. The Director of Nursing acknowledged the oversight and the facility policies require physician orders upon admission for immediate care.
Deficiencies (1)
F 0695: The facility failed to provide safe and appropriate respiratory care for a resident with a tracheostomy by lacking physician's orders for tracheostomy care, oxygen, oxygen humidity, suctioning, and oxygen saturation monitoring until 7/11/24.
Report Facts
Oxygen flow rate: 2
Airvo setting: 20
Feeding rate: 70
Feeding flush volume: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Identified the lack of physician's orders and provided facility policies during the inspection |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 55
Deficiencies: 0
Date: Aug 12, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00439071.
Complaint Details
Complaint IN00439071 was investigated and found to have no deficiencies related to the allegations.
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.
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
Date: Jul 17, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00437362.
Complaint Details
Complaint IN00437362 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00437362 were cited. The facility was found to be in compliance with applicable regulations.
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
Date: May 31, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00435395.
Complaint Details
Complaint IN00435395 was investigated and found to have no deficiencies related to the allegations.
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.
Report Facts
Medicare residents: 3
Medicaid residents: 36
Other residents: 13
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 31, 2024
Visit Reason
The inspection was conducted following complaints regarding misappropriation of a resident's funds by an employee. The investigation was initiated after allegations that an administrator used a resident's debit card without permission.
Complaint Details
This Federal tag relates to Complaints IN00416811 and IN00417628. The complaint was substantiated with findings of misappropriation of resident funds by an employee.
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 systemic changes including staff education and audits were implemented.
Deficiencies (1)
F 0602: The facility failed to protect a resident's belongings, resulting in an employee misappropriating $15,179.18 from a resident's debit card without consent. The issue was corrected prior to the survey with systemic safeguards implemented.
Report Facts
Amount misappropriated: 15179.18
Number of unauthorized transactions: 22
BIMS score: 7
SLUMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADM 12 | Facility Administrator | Employee who misappropriated resident funds |
| BOM 13 | Business Office Manager | Employee who detected suspicious activity and assisted in investigation |
| RDO | Regional Director of Operations | Conducted investigation and reported findings to police |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 1
Date: Jan 31, 2024
Visit Reason
The visit was conducted to investigate complaints IN00416811, IN00417628, and IN00419803 concerning allegations of misappropriation of resident property.
Complaint Details
Complaints IN00416811 and IN00417628 were substantiated with federal/state deficiencies cited at F602. Complaint IN00419803 was not substantiated with no deficiencies cited.
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.
Deficiencies (1)
Failure to ensure a resident debit card was protected from diversion, resulting in unauthorized spending of $15,179.18 by an employee.
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
Date: 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
Date: 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.
Deficiencies (8)
Failed to conduct exercises to test the emergency plan at least twice per year including unannounced staff drills.
Failed to implement emergency power system inspection, testing, and maintenance requirements; missing weekly generator testing records for several weeks.
Barrier door set on the 100 hall did not open properly, impeding means of egress.
Failed to conduct quarterly fire drills for one quarter on the day shift.
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.
Failed to ensure annual inspection and testing of all fire door assemblies including the door to the oxygen transfilling room.
Failed to maintain written records of weekly generator inspections for 3 of 52 weeks.
Failed to properly secure two portable oxygen cylinders in the oxygen storage and transfilling room.
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
Routine
Deficiencies: 10
Date: Aug 11, 2023
Visit Reason
Routine inspection of Alpha Home - A Waters Community nursing facility to assess compliance with regulatory requirements including resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including call light accessibility, advanced directive documentation, home-like environment maintenance, accurate resident assessments, smoking policy compliance, nutrition and hydration management, respiratory care, dementia care activities, and dietary consistency adherence.
Deficiencies (10)
F 0558: Facility failed to ensure call light was within reach for a resident able to use it independently.
F 0578: Facility failed to ensure a resident had an order for an advance directive.
F 0584: Facility failed to provide a home-like environment for a resident due to unmade, dirty bed and stored equipment in the resident's room.
F 0641: Facility failed to ensure accurate resident assessments and update Minimum Data Set (MDS) information after resident condition changes for multiple residents.
F 0657: Facility failed to revise a care plan for a resident who did not smoke cigarettes as previously documented.
F 0689: Facility failed to ensure residents did not keep smoking materials independently against policy and failed to implement person-centered assessments and care plans for smoking residents.
F 0692: Facility failed to provide adequate nutrition and hydration including failure to provide upgraded diet and adaptive snacks for a resident with weight loss and dysphagia.
F 0695: Facility failed to provide safe and appropriate respiratory care including cleaning oxygen concentrator filters and ensuring emergency equipment was accessible for a resident with tracheostomy.
F 0744: Facility failed to provide appropriate adaptive activities for a resident with dementia who was NPO and unable to participate in group activities.
F 0805: Facility failed to ensure a resident received thickened liquids as ordered related to dysphagia.
Report Facts
Residents reviewed for call light accessibility: 9
Residents reviewed for home-like environment: 9
Residents reviewed for MDS accuracy: 8
Residents reviewed for smoking policy compliance: 9
Weight loss: 5
Residents reviewed for respiratory care: 4
Residents reviewed for dementia care: 2
Residents reviewed for dietary consistency: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 14 | Registered Nurse | Administered nutritional tube feeding to Resident 40 |
| DON | Director of Nursing | Provided policies and indicated expectations for care and equipment maintenance |
| ED | Executive Director | Provided facility policies and care expectations, interviewed regarding resident care |
| RNC | Regional Nurse Consultant | Provided policies and participated in record reviews and observations |
| MDSC | MDS Coordinator | Interviewed regarding MDS assessment errors |
| AD | Activity Director | Observed assisting residents with activities and smoking breaks |
| MM 12 | Maintenance Man | Interviewed regarding oxygen concentrator servicing and room conditions |
Inspection Report
Annual Inspection
Census: 56
Capacity: 56
Deficiencies: 10
Date: Aug 11, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00411354.
Complaint Details
Complaint IN00411354 was investigated with no deficiencies related to the allegations cited.
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.
Deficiencies (10)
Failed to ensure call light was within reach of Resident 26 who was able to use it independently.
Failed to ensure residents had orders for advance directives; Resident 29 lacked an order until corrected.
Failed to provide a safe, clean, comfortable, home-like environment; Resident 26's room contained an unmade, dirty mattress and clutter.
Failed to accurately update Minimum Data Set (MDS) assessments for amputations, hospice status, anticoagulant use, and Level II assessments for multiple residents.
Failed to revise care plan for Resident 31 who did not smoke, but care plan indicated smoker.
Failed to ensure residents did not keep smoking materials independently against facility policy and without appropriate assessment or monitoring for 9 residents.
Failed to provide prescribed diet, weekly weights as ordered, and alternative snacks/hydration during scheduled snack activities for Resident 44.
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.
Failed to provide alternative or adaptive activities for Resident 40 with dementia who was NPO and unable to participate in scheduled activities.
Failed to ensure Resident 3 received thickened liquids as ordered; regular water was found in her room instead of nectar thickened liquids.
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
Date: 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
Date: Jun 15, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00407897 and IN00410268.
Complaint Details
Complaint IN00407897 - No deficiencies related to the allegations are cited. Complaint IN00410268 - No deficiencies related to the allegations are cited.
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.
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
Date: Mar 23, 2023
Visit Reason
This visit was for the investigation of complaints IN00396344, IN00397054, and IN00397818.
Complaint Details
Complaints IN00396344, IN00397054, and IN00397818 were investigated and no deficiencies related to the allegations were cited.
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.
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
Date: Oct 31, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00385839.
Complaint Details
Complaint IN00385839 was investigated and determined to be unsubstantiated due to lack of evidence.
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.
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
Date: 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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