Alpine Health and Rehabilitation Center

Inspectors wroteBased on interviews and record review, the facility failed to ensure accurate skin evaluations were completed in a timely manner for one resident (#1) out of three residents reviewed. Resident #1 was diagnosed with a Stage IV pressure ulcer to the sacrum and osteomyelitis and sent to a higher level of care for treatment.

Inspectors wroteBased on record review and interviews, the facility did not complete and/or update the level I pre-admission screening and resident reviews (PASSARs) for residents with qualifying medical diagnoses for six (#4, #5, #9, #13, #18 and #36) out of 18 residents reviewed for PASSARsFindings Included: 1. A review of Resident #9's admission record revealed an original admission date of 11/4/24, and a re-admission date of 11/2/25, with diagnoses to include but not limited to; other recurrent depressive disorders, post-traumatic stress disorder, chronic, anxiety disorder unspecified, and alcohol abuse with intoxication, unspecified. A review of Resident #9's annual minimum data set (MDS) for medications, dated 11/7/25, revealed the following under high-risk drug classes: antidepressant usage. A review of Resident #9's care plan revealed the following focus areas to include: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain an effective infection prevention and control program by failing to 1.) ensure hand hygiene was offered for eight ( 20A, 21B ,22B, 23A,24A 24B, 25A, 26A, 26B, 28B) of the eight rooms observed prior to meals. (2) The facility failed to ensure staff wore appropriate personal protective equipment (PPE) while handling laundry for the facility in one of one laundry rooms. 3.) The facility failed to follow infection control practices related to respiratory equipment for one (#2) of two residents samples with oxygen. Findings Included: On 01/05/2026 at 10:40 a.m., observed Resident #2 sitting up in bed with the tray table in front of them. The resident was fully dressed and observed using oxygen with a nasal cannula in place. The resident stated they used oxygen during the day. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident council meetings were documented as required for six of six months of resident council minutes requested. The facility could not demonstrate that they acted upon grievances voiced during resident council meetings. Findings Included: A review of the grievance log from June 2025 to December 2025 did not reveal any entries from Resident Council. During the Resident Council (RC) meeting on 1/7/2026 at 1:26 p.m. The RC members said they are not sure who the Grievance Official. The Grievance Official changes frequently, and they are not informed when the changes occur. The RC members said the staff never discuss the rationale behind unresolved issues, but We [the facility] will look into it is the answer received without resolution. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain a safe, clean, comfortable homelike environment related to rusted equipment, unpainted, damaged and uncleanable surfaces in the laundry room and 13 (2,6,10,11,14,16,19,20,21,23,26,28 and 29) of 28 resident rooms toured and one of one laundry room toured

Inspectors wroteBased on record review and interview, the facility failed to implement its grievance process. The facility did not ensure resident's grievances from Resident Council were received, investigated, and a resolution provided or discussed for six of six months of resident council meeting minutes reviewed. Findings Included: Resident #9 said the residents are not sure who the Grievance Official is currently. The Grievance Official changes, and they must look at the paper on one of the office doors to find out the current person. The staff never discuss the rationale behind unresolved issues. We will look into it is the answer the residents receive all the time without any resolution. On 1/7/26 at 5:12 p.m., an interview with the NHA was conducted. She said the activities director had no documentation of the resident council minutes. [...]

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure the appropriate staff member referred one (#7) with serious mental disorder(s)/diagnoses to the State's Mental Health authority for Level II Preadmission Screening and Resident Review (PASRR) out of 18 residents sampled. A record review of Resident #7's admission Record showed an original admit date of 11/27/2025 with diagnoses to include but not limited to:Epilepsy, unspecified, not intractable , without status epilepticusAnxiety disorder, unspecifiedLatent syphilis, unspecified as early or lateBipolar disorder, current episode mixed, severe, with psychotic featuresMajor depressive disorder, recurrent, unspecifiedAlcohol abuse with intoxication, unspecifiedA record review of Resident #7's PASSR dated 01/27/2025 showed in Section A. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility did not 1. Ensure a care plan was initiated for one (#4) of two residents reviewed for mental health diagnoses; and 2. did not ensure care plans were initiated and/or implemented for two (#34 and #23) of three residents reviewed for smoking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activities of daily living, specifically nail care was provided for three (#5, 21, and 43) of six residents reviewed who required assistance with personal hygiene.

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure weekly skin sweep evaluation were done for three (13, 36, and 5) out of three residents.

Inspectors wroteBased on observation, record review, and interviews, the facility did not ensure residents were free from accident hazards for two (#34 and #23) of three residents reviewed for smoking as evidenced by residents not being evaluated, care plan interventions were not developed and implemented, and the smoking procedure/policy was not followed.

Inspectors wroteBased on observations, interviews and record review the facility did not ensure narcotic medications were provided in a timely manner for three (#5, 10, and 18) out of three residents reviewed.

Inspectors wroteBased on observations, staff and resident interviews, and record reviews, the facility failed to maintain an effective pest control management system in one (East Wing) of two Wings and in one (room [ROOM NUMBER]) of twenty-eight rooms. Findings Included: During an interview on 01/07/2026 at 11:14 AM, Resident #8 stated, The rooms have pests and we need someone to help us keep the bathrooms and rooms clean. During an interview on 01/08/2026 at 1:52 PM with Staff J, Certified Nursing Assistant (CNA) stated, If I see bugs, I will tell the Nursing Home Administrator (NHA) or the Director of Nursing (DON), however I don't use the bug book to report pest sightings. [...]

Inspectors wroteOn 12/13/2023 at 11:45 a.m. an ice chest on the [NAME] Hallway was observed to have brown and pink bio growth around the upper edge of the chest, the ice scoop was sitting in a tray with water and pink bio growth was observed in the corners. (Photographic Evidence Obtained) An interview was conducted with the Assistant Director of Nursing (ADON) on 12/13/2023 at 11:53 a.m. The ADON confirmed the ice chest had pink and brown bio growth around edges as well as in the ice scoop tray. The ADON stated, I thought they cleaned this yesterday with the ice machine, but I guess they did not. The ice chest and scoop should not be left like this. Review of the facility's policy titled, Cleaning and Sanitation, dated September 2021, showed, The facility promotes a clean and sanitary environment for its employees, residents and visitors. [...]

Inspectors wroteBased on observations and interviews the facility failed to provide a clean and home-like environment for three resident shared bathrooms (Rooms 25/27, 12/13, and 14/15) out of 17 bathrooms sampled for environmental services.

Inspectors wroteBased on record review and staff interviews, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for 10 residents (4, 7, 15, 19, 22, 28, 31, 40, 42, 44) of 33 sampled residents.

Inspectors wroteBased on interview and record review the facility failed to maintain accurate medical records related to insulin documentation for two residents (#28 and #27) out of four residents reviewed for medication administration.

Inspectors wroteBased on observation, resident interview, staff interview, and record review the facility failed to ensure one resident (#27) out of 3 residents observed for insulin medication administration received care in accordance with professional standards of practice related to the time of administration of short acting insulin, in relation to the time the resident received her lunch meal.

Inspectors wroteBased on record review and interview the facility failed to ensure one resident (#35) out of four residents reviewed had a smoking evaluation completed to ensure safety during smoking.

Inspectors wroteBased on observation, interview and record review the facility failed to provide intravenous (IV) care according to standards of practice for one resident (#40) out of one resident reviewed.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure respiratory care and services was consistent with professional standards of practice for one resident (#4) out of 33 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that resident council meetings were facilitated and failed to provide and train a designated staff person to assist with providing for the council meeting process for July 2021, August 2021, and September 2021. Due to this failure, there was no resident council activity for those months. Findings Included: The Nursing Home Administrator (NHA) was interviewed about the resident council during the survey entrance conference conducted on 10/04/21 at 9:32 a.m. He confirmed there was a council and identified the president as Resident # 35. On 10/04/21 at 4:46 p.m., the NHA was asked to provide the minutes from the past 3 months of resident council meetings (July 2021, August 2021, September 2021) after gaining permission from the council president. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident food was stored under sanitary conditions in one of one refrigerator/freezer designated for resident food storage The facility failed to ensure that foods were labeled properly and discarded for food safety, failed to ensure no staff food was stored with resident food items, and failed to monitor the refrigerator/freezer for safe food storage temperatures. A tour of the facility resident nourishment pantry areas was conducted on 10/5/21 at 12:00 p.m. with Staff C, Registered Nurse (RN), Unit Manager (UM). She confirmed that there was only one refrigerator/freezer in the facility used for storage of resident's personal food, including food brought in by visitors and family. She revealed the refrigerator/freezer was located in the main dining room. [...]

Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to implement an ongoing resident centered activities program that incorporated the residents' interests for two (Resident #16 and Resident #24) of two sampled residents investigated for activities.

Inspectors wroteBased on record review and interview, the facility failed to ensure that behavior and side effects monitoring was recorded for two (Residents # 50 and #28) of five sample residents who were reviewed for unnecessary medications.