Inspection Reports for
Alpine Breeze Health and Wellness

The complaint investigation found that Resident #1 threw a rock during a supervised smoke break, hitting Resident #2 on the back of the head, resulting in a laceration and hospital evaluation. Resident #2 pressed charges. The facility placed Resident #1 on 1:1 observation and notified the physician and family. The incident was not deemed predictable prior to the event.

The facility failed to ensure Resident #2 was free from physical abuse when Resident #1 threw a rock that hit Resident #2, causing a 3 cm laceration and hospital visit. The facility responded by placing Resident #1 on 1:1 supervision and providing staff education on abuse prevention. The deficiency was corrected promptly.

The facility's water was shut off due to non-payment, impacting 113 residents. The facility was on a shut off list for non-payment of an outstanding balance of $14,000.81. Corrective actions were implemented, including setting up auto pay for vendors and partial payment to Vendor A, which restored water service.

The complaint was substantiated involving financial exploitation of Resident #1 by CNA A who made unauthorized withdrawals totaling $617.89 from the resident's bank account using Cash App. The resident was cognitively intact and reported the incident. The facility notified the Administrator, Director of Nursing, family, physician, local police, and CMS. CNA A was terminated and denied knowledge of the debit card. Police investigation was ongoing.

The facility failed to prevent the financial exploitation of one resident by a former CNA who used the resident's bank card for unauthorized transactions totaling $617.89. The facility replaced the missing funds and educated staff on abuse and exploitation protocols. The incident was reported to law enforcement and investigated.

The complaint involved Resident #1 who was discharged without proper notice including appeal rights. The resident was discharged to a family member's home who refused to accept the resident, resulting in an emergency discharge to the hospital. The facility refused to readmit the resident citing safety concerns due to the resident bringing unknown males into the facility and attempting to become pregnant, which the facility was not equipped to manage. The Missouri Department of Health & Senior Services Appeals Unit dismissed the facility's discharge notice due to inadequate notice and ordered the resident's return. The resident filed appeals and had legal representation.

The facility failed to provide a discharge notice that included appeal rights and the location of transfer for one resident. Additionally, the facility did not permit the resident to return after hospitalization, citing safety concerns related to the resident's behavior and pregnancy intentions. The discharge notice was found to be inadequate and dismissed by the state appeals unit.

The facility had multiple deficiencies including failure to ensure resident privacy and dignity during care, inadequate call light accessibility, untimely submission of third party liability forms, poor environmental cleanliness, failure to follow wound care orders and documentation, improper use and monitoring of pressure relief mattresses, unsafe resident transfers, inadequate infection control handwashing practices, failure to monitor dialysis sites, improper food temperature maintenance, poor dietary supplement documentation, incomplete hospice documentation, delayed invoice payments, and inadequate pest control measures.

The complaint investigation found that the facility did not provide proper notice for an immediate discharge of Resident #1 to the hospital. The discharge letter was prepared by the Administrator and delivered by the Director of Nursing. Family members and staff interviews confirmed the discharge was not appropriately planned and the facility would not accept the resident back. The discharge was due to behaviors the facility could not manage, and the facility acknowledged it was not supposed to discharge a resident to the hospital.

The facility failed to provide timely notification to the resident and relevant parties before an immediate discharge to the hospital. The discharge was due to resident behaviors, and the facility did not have an appropriate discharge plan, discharging the resident to the hospital instead of a suitable location.

The complaint investigation focused on the failure to provide increased behavioral monitoring for Resident #1, who exhibited aggressive behaviors leading to a physical altercation with Resident #2. The investigation found that the facility did not update the resident's medical record or care plan with new behaviors or interventions, nor did it initiate increased monitoring upon the resident's return from the hospital. The facility ruled out abuse, determining the altercation was accidental. Interviews with staff revealed gaps in communication and care plan updates.

The facility failed to provide increased behavioral monitoring and updated care plans for a resident with dementia exhibiting aggressive behaviors, leading to a physical altercation between two residents. Additionally, the facility failed to post signage restricting resident access to a renovation area and did not ensure handrails were installed on both sides of several resident halls.

The facility management company failed to ensure timely payments to vendors, leading to water shut off for non-payment and outstanding balances for sewer and fire alarm services. Immediate jeopardy was identified but later removed after corrective actions. Multiple staff and residents reported frustration and impact on care due to service interruptions.

The facility was found deficient in multiple areas including failure to offer and document advanced directives, presence of mouse droppings and odors in resident rooms, failure to report and investigate an injury of unknown origin, inaccurate coding of assessments, lack of care plan meetings, improper catheter care, inadequate nutritional care and meal service, failure to maintain dialysis communication and orders, incomplete staff training and competencies, poor food temperature control, kitchen sanitation issues, and maintenance deficiencies affecting resident safety and comfort.

The facility was found deficient in multiple areas including failure to submit required Third Party Liability forms timely, inadequate provision and documentation of resident activities, unsafe resident transfers, significant resident weight loss with inadequate nutritional monitoring, food safety and sanitation issues in the kitchen, improper storage of visitor food, lapses in infection control practices, and maintenance deficiencies affecting resident safety and comfort.