A list of the most recent deficiencies for Alpha Home - A Waters Community. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-01-31 | 2023-09-28 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-30 | 2023-09-21 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-08-30 | 2023-09-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-30 | 2023-09-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-30 | 2023-09-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-08-30 | 2023-09-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-30 | 2023-09-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-30 | 2023-09-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-30 | 2023-09-21 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-08-11 | 2023-09-08 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-08-11 | 2023-09-08 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-08-11 | 2023-09-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-11 | 2023-09-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-08-11 | 2023-09-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-11 | 2023-09-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-11 | 2023-09-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-11 | 2023-09-08 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-08-11 | 2023-09-08 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-08-11 | 2023-09-08 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-05-12 | 2022-07-08 | N |
| Meet other general requirements. | Fire Safety | 2022-05-12 | 2022-07-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-05-12 | 2022-07-08 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-05-12 | 2022-07-08 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-05-12 | 2022-07-08 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-05-12 | 2022-07-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-12 | 2022-07-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-12 | 2022-07-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-12 | 2022-07-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-12 | 2022-07-08 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-05-12 | 2022-07-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-12 | 2022-07-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-13 | 2022-07-07 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-13 | 2022-07-06 | N |
| Provide activities to meet all resident's needs. | Health | 2022-04-13 | 2022-07-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-13 | 2022-07-06 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-03-02 | 2022-05-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-13 | 2022-05-12 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-04-13 | 2022-05-12 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-04-13 | 2022-05-12 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2022-04-13 | 2022-05-12 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-04-13 | 2022-05-12 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-04-13 | 2022-05-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-13 | 2022-05-12 | N |
| Respond appropriately to all alleged violations. | Health | 2022-04-13 | 2022-05-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-13 | 2022-05-12 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-04-13 | 2022-05-12 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-04-13 | 2022-05-12 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-04-13 | 2022-05-12 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-04-13 | 2022-05-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-04-13 | 2022-05-12 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-13 | 2022-05-12 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-04-13 | 2022-05-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-13 | 2022-05-12 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-04-13 | 2022-05-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-13 | 2022-05-12 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2022-04-13 | 2022-05-12 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-04-13 | 2022-05-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-13 | 2022-05-12 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-01-12 | 2022-02-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-12 | 2022-02-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-12 | 2022-02-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-16 | 2022-02-01 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-01-24 | 2022-01-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-28 | 2021-10-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-28 | 2021-10-27 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-09-28 | 2021-10-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-12 | 2021-07-07 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-06-12 | 2021-07-07 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-06-12 | 2021-07-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-12 | 2021-07-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-12 | 2021-07-07 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-06-12 | 2021-07-07 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-06-12 | 2021-07-07 | Y |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2021-04-23 | 2021-05-23 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-04-23 | 2021-05-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-23 | 2021-05-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-23 | 2021-05-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-23 | 2021-05-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-23 | 2021-05-23 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-04-23 | 2021-05-23 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-04-23 | 2021-05-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-23 | 2021-05-23 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-04-23 | 2021-05-23 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2019-12-16 | 2020-01-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-16 | 2020-01-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-12-16 | 2020-01-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-16 | 2020-01-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-12-16 | 2020-01-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-16 | 2020-01-15 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-12-16 | 2020-01-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-12-16 | 2020-01-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-12-16 | 2020-01-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-18 | 2019-10-18 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-09-18 | 2019-10-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-18 | 2019-10-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-09-18 | 2019-10-18 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2019-09-18 | 2019-10-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-18 | 2019-10-18 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-09-18 | 2019-10-18 | N |
| Keep all essential equipment working safely. | Health | 2019-09-18 | 2019-10-18 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-09-18 | 2019-10-18 | N |
