Alpha Home - a Waters Community

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was allowed to return to the facility after a psychiatric hospitalization for 1 of 3 residents reviewed for transfer and discharge (Resident E).

Inspectors wroteBased on record review and interview, the facility failed to ensure a notice of transfer or discharge (required notice which instructs how to appeal a discharge) and bed hold policy were provided to a resident's representative at the time of a hospital discharge and a 30-day notice was provided for a facility-initiated discharge for 1 of 3 residents reviewed for discharge (Resident E).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide documented responses, follow-up, or written resolutions to several recurring concerns raised by the Resident Council. This practice failed to ensure residents' concerns were acknowledged and resolved, and resulted in continued unmet needs related to environmental, dietary, nursing, and activity services and had the potential to affect 5 of 5 residents who participated in the Resident Council Meeting.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities as scheduled on the posted monthly activity calendar, failed to deliver activities with adequate staff engagement or supervision, and failed to implement a structured, individualized or meaningful activity program to meet the needs of residents with dementia. This deficient practice had the potential to affect 21 of 21 residents who resided in the secured memory care unit and 5 of 5 residents who attended and participated in the Resident Council Meeting.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide individualized, person-centered dementia care for multiple residents with cognitive impairment by: Responding to behaviors with restraint-like practices instead of dementia-appropriate interventions, using as needed (PRN) medications before nonpharmacological interventions, and failing to provide meaningful activities or engagement. This deficient practice had the potential to effect 21 of 21 residents residing on the secured memory care unit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from the use of physical restraints when staff placed a resident, (Resident 56) in a heavy immobile chair and positioned the table over the arms of the chair to prevent her from standing or moving freely. This deficient practice constituted a restraint by restricting the resident's ability to move freely for 1 of 1 resident reviewed for restraints.

Inspectors wroteBased on record review and interview, the facility failed to properly reconcile medications for a resident who was discharging home for 1 of 3 residents reviewed (Resident 67).

Inspectors wroteBased on record review and interview, the facility failed to code the resident's Minimum Data Set (MDS) assessment correctly for the types of medications that residents receive for 3 of 5 residents reviewed for accuracy (Resident 3, 69, and 6).

Inspectors wroteBased on record review and interview, the facility failed to complete a new level of care assessment for a resident when her 30 days expired for 1 of 5 residents reviewed for PASRR (Pre-admission Screening and Resident Review) (Resident 69).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was clean and appropriately dressed and groomed and failed to ensure a resident's bedding was appropriately changed when soiled for 1 of 1 resident reviewed for concerns with Activities of Daily Living (ADLs) (Resident 13).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was consistent communication between the facility and the dialysis center regarding the residents' care for 2 of 2 residents (Residents 24 and 6) reviewed for dialysis services.

Inspectors wroteBased on record review and interview, the facility failed to obtain a urine culture and sensitivity after a resident was found on the floor next to her bed for 1 of 3 residents reviewed (Resident 2).

Inspectors wroteBased 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).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall prevention interventions were individualized and implemented, and fall follow-up assessments and interventions were completed for 1 of 3 residents reviewed for falls (Residents B).

Inspectors wroteBased on observation and interview, the facility failed to ensure medication and biologicals were stored according to facility policy for 1 of 1 treatment carts observed for medication and biological storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the potential for accidents when transportation staff were not trained on new bus equipment and failed to install a safety lap belt, which resulted in actual harm when a resident slid out from his wheelchair on the bus and sustained a L1 vertebra fracture with a 20% height loss for 1 of 2 residents reviewed for falls (Resident 11). The deficient practice was corrected by 1/18/24 prior to the start of the survey and was therefore Past Noncompliance.

Inspectors wroteBased on interviews and record review, the facility failed to ensure Resident Council grievances were followed up on and reported back to the Resident Council for review and approval. This deficient practice had the potential to effect 4 of 54 residents who attended the Resident Council meeting.

Inspectors wroteBased on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) for 5 of 5 residents reviewed for MDS accuracy (Resident 9, 47, 12, 11, and 33).

Inspectors wroteBased on observation and interview, the facility failed to date medications when opened for 1 of 3 medication carts reviewed (medication cart 300) and 1 of 3 treatment carts (treatment cart 3).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure dignity for a female resident with long facial hair for 1 of 1 resident reviewed for dignity (Resident 33).

Inspectors wroteBased on record review and interview, the facility failed to add comprehensive care plans for 2 of 2 residents reviewed for comprehensive care plans (Residents 47 and 12).

Inspectors wroteBased on record reviews and interviews, the facility failed to update care plans with changes in resident care for 2 of 3 residents reviewed for care plan revision (Resident 25 and 12).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident (Resident 11) who experienced a fall was not moved until after a medical assessment was completed to prevent the potential for worsening any known or unknown injuries for 1of 1 of residents reviewed for accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident, (Resident 35) received treatments and services to prevent the worsening of contracture in her hand and wrist for 1 of 1 residents reviewed for range of motion.

Inspectors wroteBased on record review and interview, the facility failed to obtain a resident's blood pressure and pulse prior to administering metoprolol (an antihypertensive medication) as ordered for 1 of 6 residents reviewed for medications(Resident 14).

Inspectors wroteBased on interview and record review, the facility failed to ensure a pharmacy recommendations to reduce an psychotropic medications were declined with adequate documentation of symptoms for 2 of 5 residents reviewed for unnecessary medications (Residents 34 and 9).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an x-ray was completed for 1 of 1 resident reviewed for x-rays (Resident 33).

Inspectors wroteBased on observation and interview, the facility failed to properly sanitize a blood glucometer meter for 1 of 5 glucometer meter (Resident 103) stored on the treatment cart.

Inspectors wroteBased on interview and record review, the facility failed to ensure the influenza vaccination was offered and the pneumonia and COVID-19 vaccinations were completed for a resident who requested them for 1 of 5 residents reviewed for vaccinations (Resident 102).

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident with a tracheostomy (trach) (an opening surgically created through the neck into the trachea to allow air to fill the lungs with a tube) had physician's orders for tracheostomy care, oxygen, oxygen humidity, suctioning, and to keep oxygen saturation (sats) greater than (>) 90% for 1 of 2 residents reviewed with a tracheostomy (Resident B).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident debit card was protected from diversion, resulting in $15,179.18 being spent by an employee without the resident's knowledge for 1 of 4 residents reviewed for misappropriation of property (Resident B). The deficient practice was corrected on 9/28/23, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure residents did not keep smoking materials independently against facility policy and without appropriate assessment or monitoring, and failed to ensure person-centered assessments and care plans revisions were implemented for 9 of 9 residents reviewed for accidents, (Residents 21, 29, 106, 43, 108, 34, 41, 6 and 105).

Inspectors wroteA. Based on observation, interview, and record review, the facility failed to ensure respiratory equipment was properly replaced, stored and placed on a residents for 3 of 4 residents reviewed for respiratory care (Residents 21, 34, and 2). B. Based on observation, interview, and record review, facility failed to clean the filter of a specialized oxygen concentrator and ensure an ambu-bag was readily accessible at bedside for a resident, who was dependent on respiratory and tracheostomy for 1 of 1 resident reviewed for tracheostomy care (Resident 26).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was in reach of a resident who was able to use it for 1 of 9 residents reviewed for call lights within reach (Resident 26).

Inspectors wroteBased on observation and interview, the facility failed to ensure a resident had an order for an advanced directive for 1 of 1 resident (Resident 29).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a home-like environment for 1 of 9 resident reviewed for home-like environments (Resident 26).

Inspectors wroteBased on record review and interviews, the facility failed to revise a care plan for a resident that did not smoke cigarettes for 1 of 6 residents reviewed for smoking (Resident 31).

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure a resident, (Resident 44) with a history of weight loss, was provided with an upgraded diet as prescribed by his physician, weekly weights were obtained as ordered and failed to provide adaptive or alternative snacks/hydration during the scheduled snack activities for 1 of 2 residents reviewed for hydration/nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with a diagnosis of dementia was provided alternative or adaptive activities for 1 of 2 residents reviewed for dementia care (Resident 40).

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that a resident received thicken liquids as ordered related to dysphagia for 1 of 7 Residents reviewed to appropriate dietary requirements (Resident 3).

Inspectors wroteBased on record reviews and interviews, the facility failed to update a resident's Minimum Data Set (MDS) information after an above the knee (AKA) amputation, accurately code level II assessments for residents with level IIs, and accurately code resident's who were receiving hospice and anticoagulant medication for 5 of 8 residents reviewed for MDS accuracy (Resident 6, 12,13, 16, and 53).