Alpine Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure that alleged violations of abuse were reported immediately to the State Survey Agency (SSA) for 3 of 3 residents reviewed for abuse. (Resident identifiers are Resident #1, #2 and #3.)

Inspectors wroteBased on interview and record review, the facility failed to ensure that alleged violations of abuse were thoroughly investigated for 2 of 3 residents reviewed for an alleged violation of abuse. (Resident identifiers are Resident #1 and #2.)

Inspectors wroteBased on interview and record review it was determined that the facility failed to ensure the appropriate use of a restraint for 1 of 1 residents reviewed for restraints (Resident identifier is #1). Findings Include:Interview on 1/20/26 at approximately 11:15 a.m. with Staff D (Licensed Nursing Assistant) revealed that he/she witnessed Staff C (Licensed Nursing Assistant) with Resident #1's back against Staff C's chest and his/her arms around Resident #1. Staff D further revealed that Resident #1's feet were off the ground while Resident #1 was moved to another area. Staff D stated that the incident occurred on or around January 1, 2026 and that he/she reported the incident on 1/14/2026. Interview on 1/21/26 at approximately 12:00 p.m. with Staff C revealed that Resident #1 was combative and had struck Staff C in the nose and genitals. [...]

Inspectors wroteBased on interview, record review, and policy review, the facility failed to implement the facility's abuse policy for reporting and investigating allegations of abuse, staff abuse training, and staff screening for 3 out of 3 allegations of abuse reviewed and 4 out of 5 staff reviewed for abuse (Resident Identifiers are #1, #2 and #3) (Staff identifiers are C, D, H and J).

Inspectors wroteBased on observation and interview, it was determined that the facility failed to provide a safe, sanitary, and homelike environment for 1 of 3 units observed.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to follow physician's order for 1 of 1 resident reviewed for pressure ulcer in a final sample of 18 residents. (Resident identifiers is #22.)

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that trauma survivors have triggers identified that may cause re-traumatization in 1 of 5 residents reviewed for behavioral and emotional status in a final sample of 18 residents. (Resident identifier is #274).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that expired medications were removed from use for 2 of 4 medication carts observed. (Resident identifiers are #3 and #35).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure appropriate sanitization of dishware in 1 of 1 kitchen observed.

Inspectors wroteBased on interview and medical record review, it was determined that the facility failed to ensure that a resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility for 1 of 1 resident reviewed for hospice services in the final sample of 18 residents. (Resident identifier is #30.)

Inspectors wroteBased on interview and record review, it was determined that the facility failed to provide the resident and/or resident's representative a timely notice of the Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) for 2 of 3 residents reviewed for beneficiary notices.(Resident identifiers are #51 and #71).

Inspectors wroteBased on record review and interview, it was determined that the facility failed to follow an established antibiotic stewardship program and system of monitoring antibiotic use for 3 out of 12 months reviewed (May, June and July 2024).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain an environment free of accident hazards by not securing lighters and cigarettes when not in use for 2 of 2 residents reviewed for smoking in a final sample of 18 residents (Resident Identifiers are #7 and #68).

Inspectors wroteBased on observation, record review and interview, it was determined that the facility failed to document and/or maintain temperature ranges according to manufacturer's instructions in 1 of 2 medication refrigerators observed and failed to dispose of expired medications in 1 of 4 medication carts observed.

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to follow Centers for Disease Control and Prevention (CDC) guidance for Enhanced Based Precautions (EBP) for 1 of 3 residents reviewed for indwelling catheter and 1 of 1 residents with a gastrostomy tube in a final sample of 18 residents (Resident Identifiers are #16 and #8).

Inspectors wroteBased on observation, interview, facility policy, and review of manufacturers' instructions it was determined that the facility failed to ensure that medications remained in a locked storage area and opened insulins were labeled with a resident identifier and an open/expiration date on 1 out of 4 medication carts observed, and that expired medications were removed from supply and multi-dose vials were labeled with an open/expiration date in 2 out of 2 medication rooms observed (Resident identifier is #27).

Inspectors wroteBased on interview and record review it was determined that the facility failed to assess pressure ulcers weekly for 2 out of 5 residents reviewed for pressure ulcers in a sample of 23 residents (Resident Identifiers are #21 and #33).

Inspectors wroteBased on observation, interview, and policy review it was determined that the facility failed to ensure that the residents' environment remained as free of accident hazards as is possible on the Memory Care Unit.

Inspectors wroteBased on interview and record review it was determined that the facility failed to ensure that residents received scheduled medications on days that they attended dialysis for 1 of 1 resident reviewed for dialysis in a final sample of 23 residents (Resident Identifier is #23).

Inspectors wroteBased on interview and record review it was determined that the facility failed to ensure that residents only received necessary medications by monitoring behaviors, using non-pharmacological interventions, or monitoring for side effects for 1 of 5 residents reviewed for unnecessary medications in a final sample of 23 residents (Resident Identifier is #72).

Inspectors wroteBased on observation, interview, and policy review it was determined that the facility failed to ensure that food was prepared and served in sanitary environment.