Alpine Health and Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF686May 11, 2026

  Based 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. Findings included: A record review of Resident #1's SBAR (Situation, Background, Assessment, Recommendation) Communication Form dated 3/11/2026 at 7:29 a.m., showed a new pressure ulcer with the primary physician and family notified. […]

• No harm, potential for more than minimal, widespreadF645Jan 8, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF880Jan 8, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Dec 14, 2023

  Based on observation and interviews the facility failed to ensure one of one ice machine for the facility and one ice chest on the [NAME] Hallway was clean and free from bio growth in the Ice Machine Room. Findings included: During an observation on 12/12/23 at 12:30 p.m. there was one ice machine in the facility located on the [NAME] Hall Ice Machine Room. The ice chute of the ice machine had a black and brown bio growth substance on the inside of the chute where the ice comes out. (Photographic Evidence Obtained) During an interview on 12/12/23 at 1:00 p.m. the Dietary Manager (DM) stated the ice machine located in the [NAME] Hall Ice Machine Room was the only ice machine for the entire facility. The DM stated the Maintenance Department was responsible for cleaning the ice machine. […]

• No harm, potential for more than minimal, patternF565Jan 8, 2026

  Based 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. […]