Alpha Home - A Waters Community

In the surveyor’s words

From the most serious findings on record at Alpha Home - A Waters Community, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Apr 13, 2022

  Based on observation, interview and record review, the facility failed to treat a resident with Diabetes Meletus as ordered by the hospital discharge instructions for diabetic medication and diabetic wound care resulting in Resident B having significant risk of hypo/[CONDITION(S)] and wound deterioration or infection and the facility also failed to ensure care was given for diabetic wound care, IV antibiotics (Resident E), and non-pressure wound care (Resident C and D) for 4 of 9 residents reviewed for quality of care. The Immediate Jeopardy began on 3/18/22 at 7:14 p.m. when Resident B was admitted to the facility from the local hospital. […]

• Immediate jeopardy, isolatedF678Jun 12, 2021

  Based on observation, interview, and record review, the facility failed to ensure residents choice of code status was documented in the medical record for 5 of 59 residents reviewed for advanced directives (Resident D, W, M, BC and N) which resulted in immediate jeopardy when the facility failed to follow the Cardiopulmonary Resuscitation (CPR) procedure for an unresponsive resident without respirations and no code status recorded resulting in death (Resident D). The Immediate Jeopardy began on [DATE] when Resident D was found unresponsive, and the nurse was unable to determine the resident's code status from the medical record. The nurse left the resident unattended and called the hospice company and the Director of Nursing (DON) for guidance. […]

• Immediate jeopardy, isolatedF684Jun 12, 2021

  Based on interview and record review, the facility failed to ensure a resident had a complete assessment after a fall and changes in condition and was sent out of the facility for treatment to the emergency room in when ordered by the physician for 1 of 4 residents reviewed for falls (Resident C). This resulted in immediate jeopardy when Resident C experienced a delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Immediate Jeopardy began on 5/5/21 at 6:40 a.m., when a Resident C had an unwitnessed, undocumented fall. The record lacked documentation of a complete set of assessments by not recording blood pressures for 7 of 9 assessments and the neuro checks ended at 11:00 a.m. Initial communication with the physician recorded at 6:40 a.m. […]

• Immediate jeopardy, isolatedF689Jun 12, 2021

  Based on observation, interview, and record review, the facility failed to ensure a resident's environment was safe from hazardous conditions to prevent the resident from falling, after the resident was observed in his room, by several staff members, not wearing shoes or grip socks, with multiple environmental hazards present, and screaming out loudly for several hours which resulted in an immediate jeopardy when the resident sustained 2 falls in one shift and died within hours of the last fall for 1 of 4 residents reviewed for falls (Resident D). […]

• Actual harm, isolatedF686May 28, 2025

  Based on record review, and interview, the facility failed to prevent the development of a stage II (partial thickness skin loss involving the dermis) coccyx wound that progressed to an unstageable (a full-thickness tissue loss where the base of the ulcer is obscured by slough [yellow, tan, gray, green, or brown tissue]) that resulted in actual harm when the resident required hospitalization and wound debridement for 1 of 3 residents reviewed for pressure ulcers (Resident B). Findings include: A confidential concern during the survey indicated a family member was not happy with Resident B's care while in the facility. Concerns included the resident was not being repositioned, or having his brief changed. […]