Mission at Alpine Rehabilitation Center

Inspectors wroteBased on observation, interview and record review the facility did not ensure, 9 of 32 sampled residents, were free from abuse and neglect. Specifically, multiple residents with cognitive impairment were identified to have sexual contact and were not assessed for capacity to consent to a sexual relationship. In addition, 2 residents eloped from the facility and were returned to the facility without the staff's knowledge. These examples were cited at an Immediate Jeopardy level. Resident identifiers: 11, 21, 25, 27, 31, 33, 36, 42 and 49. NOTICE On 8/8/25 at 1:15 PM, Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to prevent various forms of abuse. [...]

Inspectors wroteBased on observation, interview and record review it was determined, for 7 of 32 sampled residents, that the facility did not implement their written policies and procedures to prevent abuse, neglect, and investigate and report allegations. Specifically, the facility did not have written policies and procedures that defined sexual abuse, how to evaluate a resident's capacity to consent to a sexual relationship and elopements. These examples were cited at an Immediate Jeopardy level. Resident identifiers: 11, 27, 33, 31, 36, 42 and 49. NOTICE On 8/8/25 at 1:15 PM, Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to implement policies and procedures to prevent various forms of abuse. [...]

Inspectors wroteBased on interview, and record review, for 10 of 32 residents sampled, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency. Specifically, the State Survey Agency was not notified of sexual relations between cognitively impaired residents, multiple resident elopements, injuries of unknown origin with some resulting in fractures, and a resident not secured in transportation vehicle. Resident identifiers: 2, 7, 11, 27, 31, 33, 36, 42, 47 and 49. NOTICE On 8/8/25 at 1:15 PM, Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to report various forms of abuse. [...]

Inspectors wroteBased on interview and record review, the facility in response to allegations of abuse, neglect, or mistreatment did not have evidence that all alleged violations were thoroughly investigated. Specifically, for 9 out of 32 sampled residents, allegations of sexual abuse, elopements, injuries of unknown origins and fractures were not investigated or the allegations were not investigated thoroughly. Resident identifiers: 2, 11, 27, 31, 33, 36, 42, 47 and 49. NOTICE On 8/8/25 at 1:15 PM, Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to investigate various forms of abuse. Notice of the IJ in Abuse was given verbally and in writing to the facility Administrator, Director of Nursing, Director of Nursing in Training, and the Chief Executive Officer. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident received adequate supervision to prevent accidents. Specifically, for 6 out of 32 sampled residents, three residents with cognitive impairment eloped from the facility, this was at an immediate jeopardy level for two of these residents. A resident was not secured in a facility van and suffered a head injury, this was at a harm level. Two residents experienced falls with no interventions put into place and one resident had injuries of unknown origin. Resident identifiers: 7, 11, 12, 36, 42 and 47. NOTICE On 8/12/25 at 2:30 PM, IJ was identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to ensure that each resident received adequate supervision to prevent accidents, specifically elopement. [...]

Inspectors wroteBased on interview and record review it was determined that the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, multiple residents were identified to be in Immediate Jeopardy and/or have experienced harm. Resident identifiers: 7,11, 12, 25, 27, 33, 31, 36, 42, 47, and 49.1. Based on interview and record review, it was determined for 7 out of 32 sampled residents that the facility did not ensure that each resident had the right to be free from abuse and neglect. Specifically, residents were not assessed for the capacity to consent to a sexual relationship. This was cited at an immediate jeopardy level. In addition, two residents without capacity were able to elope from the facility. [...]

Inspectors wroteBased on interview, observation, and record review it was determined that the facility did not establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. Specifically, multiple residents were identified to be in Immediate Jeopardy (IJ) related to abuse and elopements and the facility did not develop and implement policies to address the underlying cause of the problems or identify how corrective actions were taken and monitored. Resident identifiers: 11, 27, 31, 33, 36, 42, and 49.

Inspectors wroteBased on interview and observation, the facility did not care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, during the lunch meal, residents were served on Styrofoam plates and provided beverages in Styrofoam cups. Resident identifier: 18 and 41.

Inspectors wroteBased on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in freezer and dry food storage room were open to the air, some walls were in disrepair, several tiles were cracked throughout the kitchen and bugs were found in the freezer.

Inspectors wroteBased on interview and record review, the facility did not have in effect a written transfer agreement with one or more hospitals approved for participation under the Medicare and Medicaid programs. Specifically, the facility did not have a hospital transfer agreement.

Inspectors wroteBased on interview and record review it was determined that the facility did not develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance Performance Improvement (QAPI) program. Specifically, the facility did not identify and prioritize problems related to resident abuse and elopements and corrective actions were not identified, monitored, or evaluated for effectiveness. The facility was found to be in non-compliance with F600, F607, F609, F610, and F689 at an Immediate Jeopardy level, indicating substandard quality of care. Resident identifiers: 7, 11, 12, 27, 31, 33, 36, 42, 47, and 49.

Inspectors wroteBased on interview and record review, it was determined for 4 out of 32 sampled residents, that the facility did not ensure that residents were free from physical or chemical restraints imposed for purposes of discipline or convenience and that were not required to treat the resident's medical symptoms. Specifically, a resident was being given risperidone for over affectionate behaviors when the resident was not exhibiting those behaviors, residents were not being monitored while on psychotropic medications, there was no follow-up when medications were ineffective, and a resident was provided anti-anxiety medication on an as needed basis for longer than 14 days without justification. Resident identifiers: 24, 25, 27, 40, and 41.

Inspectors wroteBased on observation, interview, and record review, it was determined that for 3 of 32 sampled residents, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. The comprehensive care plan must describe the services that were to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being. Specifically, care plans were not updated when there was a change in the resident's condition and therefore were not reflective of the services required for the residents to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Resident identifiers: 12, 42, and 47.

Inspectors wroteBased on interview and record review, the facility used individuals working in the facility as a nurse aide for more than 4 months, on a full-time basis. Specifically, seven Nursing Assistants were providing resident cares despite working at the facility for more than 120 days and not being certified.

Inspectors wroteBased on observation and interview, the facility did not have menus that met the nutritional needs of residents in accordance with established nutritional guidelines, did not follow the menu, and although the menus were reviewed by the facility's dietitian, did not demonstrate nutritional adequacy given the resident population. Specifically, the menus were altered from their original form to include the removal of the continental breakfast, a snack during the lunch time, and a larger dinner meal. A snack was then offered in the evening, although it could not be determined to be substantial to meet nutritional needs. Resident identifiers: 5, 18 and 25.

Inspectors wroteBased on observation, interview, and record review, it was determined for 2 of 32 sampled residents, that the facility went over 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack was served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span. Specifically, a resident was provided late breakfasts and another resident experienced weight loss with no nourishing evening snack documented. Resident identifiers: 12 and 25.

Inspectors wroteBased on interview and record review, the facility did not provide training to their staff that at a minimum educated staff on activities that constituted abuse, neglect, exploitation, and misappropriation of resident property; procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property; and resident abuse and neglect prevention.

Inspectors wroteBased on interviews and facility policy review, the facility failed to conduct mandatory training for all staff on the facility's quality assurance and performance improvement (QAPI) program. This deficient practice affected all residents who currently resided in the facility.

Inspectors wroteBased on interview and record review it was determined, for 1 of 32 sampled residents, that the facility did not notify the resident's physician when there was a need to alter treatment or a significant change in the resident's physical, mental, or psychosocial status. Specifically, a resident reported that his as needed (PRN) medication to treat symptoms of Parkinson's Disease was ineffective and the physician was not notified. Additionally, a resident reported that their TUMS medication was ineffective in treating their symptoms of reflux and the physician was not notified. Resident identifiers: 24 and 41.

Inspectors wroteBased on interview and record review it was determined, for 1 of 32 sampled residents, the facility did not ensure an assessment accurately reflected the resident's status. Specifically, a resident was not assessed for activities on the Minimum Data Set (MDS) assessment. Resident identifiers: 41.

Inspectors wroteBased on interview and record review it was determined, for 1 of 32 residents sampled, that the facility did not ensure that residents admitted to the facility with a mental disorder (MD) or intellectual disability (ID) and identified on the Pre-admission Screening/Resident Review (PASRR) Level II as requiring specialized services, received care and services appropriate to meet their needs. Specifically, a resident's PASRR Level II identified that the resident required specialized rehabilitative services (SRS) and those services were not arranged for or provided by the facility. Resident identifier: 11.

Inspectors wroteBased on observation, interview, and record review, it was determined that for 1 of 32 sampled residents the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition. Specifically, a resident was not assisted to eat during mealtimes. Resident identifier: 12.

Inspectors wroteBased on observation, interview, and record review, it was determined that for 2 of 32 sampled residents the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise. Specifically, 2 residents experienced significant weight loss and one of the residents required cueing to eat and did not receive it. Resident identifiers: 25 and 33.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 out of 32 sampled residents, that the facility did not provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, a resident identified as having behavioral outbursts and was involved in a sexual abuse incident did not receive any behavioral health services nor was an evaluation provided after the incident. Resident identifier: 11.

Inspectors wroteBased on interview and record review it was determined, for 1 of 32 sampled residents that the facility did not ensure that the resident's medication regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons listed above. Specifically, monitoring of physician ordered parameters to hold a blood pressure medication when the systolic blood pressure was less than 130 was not done, and the medication was administered when it should have been held. Resident identifier: 40.

Inspectors wroteBased on observation, interview, and record review, it was determined for 2 out of 32 sampled residents, that the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Specifically, one resident was not provided breakfast and received late meals; and another resident's lunch consisted of a bowl of fruit salad. Resident identifiers: 12 and 20.

Inspectors wroteBased on interview and record review it was determined, for 4 out of 32 sampled residents, that the facility did not maintain medical records on each resident that were complete; accurately documented; readily accessible; and systematically organized. Specifically, staff reported multiple incidents of abuse between residents and no documentation could be found of the incidents in the resident's medical records, and the facility did not have evidence that the allegations of abuse were investigated. Additionally, a resident's electronic medical records banner did not match the resident's Physician Order for Life Sustaining Treatment (POLST) form that indicated the type of resuscitation measures the resident selected. Resident identifiers: 5, 11, 12, and 49.

Inspectors wroteBased on observation and interview it was determined, for 2 of 32 sampled residents, that the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, when food was served in the hallways during the lunch hour, it was not covered as it was transported down the hallway between rooms in accordance with safe food handling practices. Resident identifier: 34, 36.

Inspectors wroteBased on interview and record review it was determined, for 1 of 32 sampled residents, that the facility did not ensure the antibiotic stewardship program included antibiotic use protocols and a system to monitor antibiotic use. Specifically, a resident was prescribed an antibiotic to treat an infection that was not susceptible to the prescribed antibiotic. Resident identifier: 25.

Inspectors wroteBased on interview and record review it was determined, for 2 out 5 residents sampled, that the facility did not ensure that the influenza and pneumococcal immunizations were offered to each resident unless medically contraindicated or the resident refused; and that each resident or the resident's representative received education regarding the benefits and potential side effects of the immunization. Specifically, a resident did not have any documented administration or declination of the pneumococcal vaccination, and a resident consented to the influenza and pneumococcal vaccinations but no documentation was found of the vaccine administration. Resident identifier: 9 and 35.

Inspectors wroteBased on observation, interview, and record review, it was determined, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 16 sampled residents, a resident tripped over a cord placed on the ground by a Certified Nursing Assistant (CNA) and suffered a patella fracture and a subarachnoid hemorrhage. Resident identifier: 21.

Inspectors wroteBased on interview and record review, the facility did not use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. Specifically, the facility did not always have a registered nurse at least 8 consecutive hours on certain weekends. Findings Include: 1. The facility's staffing data report from 4/1/23 to 6/30/23 was reviewed. The report documented No RN [registered nurse] hours as an area of concern, indicating that there were four or more days within the quarter with no RN hours. The facility's staffing schedules from August 2023 to November 2023 were reviewed. -There was no RN scheduled on 8/12/23. -There was no RN scheduled on 8/13/23. - There was no RN scheduled on 8/27/23. - There was no RN scheduled on 10/14/23. - There was no RN scheduled on 10/15/23. - There was no RN scheduled on 10/28/23. - There was no RN scheduled on 10/29/23. [...]

Inspectors wroteBased on interview and record review, it was determined that for 1 out of 16 sampled residents, that the facility did not ensure that residents were free from abuse. Specifically, a Certified Nursing Assistant verbally and physically abused a resident during cares. Resident identifier: 13.

Inspectors wroteBased on observation and interview, the facility did not label all drugs and biologicals used in the facility in accordance with currently accepted professional principles and included appropriate accessory instructions and the expiration date when applicable. Specifically, narcotics were repackaged into the narcotic medication cards.

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure that each resident's medical record included documentation that indicated that the resident or resident's representative was provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunizations; and that the resident either received the influenza and pneumococcal immunizations or did not receive the influenza and pneumococcal immunizations due to medical contraindications or refusal. Specifically, for 2 out of 5 sampled residents, residents did not have influenza and pneumococcal immunization documentation in their medical records and no documentation could be found that they were offered, received or declined the vaccine. Resident identifier: 3 and 18.

Inspectors wroteBased on interview and record review, it was determined for 1 of 16 sampled residents, that the facility did not ensure that the residents were free of significant medication errors. Specifically, a resident was given the incorrect Oxycodone dosage for 14 days. Resident identifier: 136. Findings Include: 1. Resident 136 was initially admitted to the facility on [DATE] and again on 11/6/23 with diagnoses which included fracture of neck of left femur, mild cognitive impairment, thrombocytopenia, age-related osteoporosis, cirrhosis of liver, splenomegaly, anemia, emphysema, acute and chronic respiratory failure with hypoxia, abdominal pain, history of falling, repeated falls, psychoactive substance abuse, bradycardia, history nicotine dependence, abdominal aortic aneurysm, essential hypertension, and chronic kidney disease. On 11/28/23 Resident 136's medical record was reviewed. [...]

Inspectors wroteBased on interview and record review it was determined, for 1 out of 5 sampled residents, that the facility did not ensure that each resident was offered the SARS-CoV-2 (COVID-19) immunization and that the medical record included documentation that the resident either received the immunization or did not due to medical contraindication or refusal. Specifically, a resident did not have the COVID-19 immunization documentation in the medical record and no documentation could be found that they were offered, received or declined the vaccine. Resident identifier: 136.

Inspectors wroteBased on observation and interview it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, there were outdated items in the refrigerator, soiled areas in the kitchen and cracked tiles throughout the kitchen on the floor.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 20 sample residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframe's to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, a resident with falls did not have an updated care plan for fall interventions and unavoidable weight loss without care plan interventions. Resident identifier: 1.

Inspectors wroteBased on interview and record review it was determined, for 1 of 20 sample residents, based on the comprehensive assessment the facility must provide care and services for bathing. Specifically, a resident was not bathed. Resident identifier: 23.

Inspectors wroteBased on interview and record review it was determined, for 1 of 20 sample residents, that the facility did not provide the necessary services to maintain good grooming and personal hygiene. Specifically, a resident did not receive showers according to their schedule for showers. Resident identifier: 25.

Inspectors wroteBased on observation, interview and record review it was determined, for 2 of 20 sample residents, that the facility did not provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. Specifically, residents in the memory care unit were not provided scheduled activities. Resident identifiers: 1 and 9.

Inspectors wroteBased on interview and record review it was determined, for 1 of 20 sample residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident sustained multiple falls without appropriate, timely, and adequate interventions. Resident identifier: 1.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 20 sample residents, that the facility did not ensure a resident maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated that this was not possible. Specifically, a resident lost weight and no nutritional interventions were implemented. Resident identifier: 1.