Alpine Fireside Health Center

In the surveyor’s words

From the most serious findings on record at Alpine Fireside Health Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 5, 2026

  Based on observation, interview, and record review the facility failed to ensure fall prevention interventions were in place for a resident with a history of falls for 1 of 3 residents (R1) reviewed for falls in the sample of 6. This failure resulted in R1 falling and sustaining a right hip fracture and right knee fracture.The findings include:R1's Progress Note dated 12/23/25 shows Approximately 1:30 AM, R1 alarm was sounding and Certified Nursing Assistant (CNA) observed R1 on floor, lying on right side. R1 complained of pain to right hip during range of motion. R1 is alert and oriented to self, has a history of falls, and has diagnosis Alzheimer's ad Dementia. […]

• Actual harm, isolatedF686Dec 7, 2025

  Based on observation, interview, and record review the facility failed to identify a pressure wound before developing into an unstageable pressure injury for one (R1). The facility also failed to prevent the development of three facility acquired State 2 pressure ulcers and one facility acquired unstageable pressure ulcer, a Stage 2 pressure ulcer worsening to unstageable, prevent cross contamination during dressing changes and apply pressure reduction devices for one (R2). This failure applies to two of three residents (R1 & R2) reviewed for pressure on the total sample of three. The findings include:1. The Physician Orders for August 2025 for R1 showed he was admitted to the facility on [DATE]. […]

• Actual harm, isolatedF689Jan 10, 2025

  Based on observation, interview, and record review the facility failed to ensure resident coffee was served at a safe temperature for 1 of 4 residents (R1) reviewed for safety and supervision in the sample of four. This failure resulted in R1 sustaining second degree burns to her thigh and calf. The findings include: The facility's incident report dated 12/31/24 showed R1 spilled coffee on herself on a Sunday (12/29/24). The report showed the physician and nurse practitioner had been notified. The report was completed by V3 (Director of Nurses). R1's undated record of admission form showed an admitted [DATE] and a discharge date of [DATE]. […]

• Actual harm, isolatedF689Apr 5, 2023

  Based on observation, interview, and record review the failed to perform a safe mechanical lift transfer for 1 of 3 residents (R1) reviewed for transfers. This failure resulted in R1 experiencing a fall from the mechanical lift, and experiencing a distal tibia and fibular fracture. The findings include: R1's 1/4/23 MDS (Minimum Data Sheet) shows R1 was admitted to the facility on [DATE]. The same document shows R1 is cognitively intact, and needs extensive assistance with all ADL (Activities of Daily Living). R1's Client Diagnostic Report printed on 4/5/23 shows her diagnoses to include a distal tibia and fibular fracture, venous insufficiency (peripheral), Vitamin D deficiency, disorder of bone density, osteoarthritis, and anxiety. […]

• Actual harm, isolatedF622Dec 30, 2022

  Based on observation, interview and record review the facility failed to ensure a resident remained in the facility when the residents needs could be met by the facility. This failure resulted in psychosocial harm to R1 on 12/21/22 when R1 was discharged from the hospital, sent to a facility, sent back to the hospital because she was COVID positive and then sent to another facility. This applies to 1 of 3 residents (R1) reviewed for discharge in the sample of 7. The findings include: On 12/28/22 at 3:34 PM, V6 (Hospital Social Worker/Case Manager) stated, Another social worker had set up the discharge of R1 to facility A and they accepted R1. I handle difficult placements and assist the other social workers. […]