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 failed to ensure a resident was free from physical abuse when Resident #1 struck Resident #2 with a rock causing a laceration and hospital visit. The facility implemented immediate corrective actions including staff education, 1:1 supervision of Resident #1, and updated care plans.

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 investigation found the facility had an immediate jeopardy due to water shutoff from non-payment. The immediate jeopardy was removed after corrective actions including payment of water bills, restoration of water service, and emergency water supply implementation.

The facility failed to ensure timely payment for water services, leading to a water shutoff that affected all residents. Immediate jeopardy was identified but later removed after corrective actions including emergency water supply and payment of outstanding balances.

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 failed to provide adequate discharge notices and did not permit a resident to return after hospitalization as required by regulations. The facility also had issues with emergency discharges and resident safety concerns related to illicit substances and visitors.

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 facility failed to provide proper notice for an immediate discharge of one sampled resident to the hospital. The facility did not meet the requirements for timely and adequate transfer/discharge notices, violating notice regulations.

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 was substantiated as the facility failed to prevent resident altercations and did not provide adequate behavioral monitoring or updated care plans. The facility ruled out abuse, determining the altercations were accidental.

The facility failed to provide appropriate behavioral monitoring and interventions for residents with dementia, resulting in resident-to-resident altercations. Additionally, the facility lacked proper signage to restrict resident access during construction and failed to install handrails on corridors as required by regulations.

The facility failed to place a 'NO EXIT' sign on the doors to the 400 Hall, which was under renovation and did not provide a clear exit path. This deficiency potentially affected 39 residents in the smoke zones of the facility.

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 failed to ensure timely payments to vendors, resulting in the running water being shut off on 4/18/23. This caused significant disruption to resident services and safety, leading to an Immediate Jeopardy that was removed on 4/19/23 after corrective actions.

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 failed to issue payments in a timely manner to electric, gas, and water companies, resulting in service disconnections. The deficiency remained uncorrected as of the follow-up inspection, with ongoing issues related to unpaid utility bills and 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 failed to maintain safe, functional, sanitary, and comfortable environmental conditions, including damaged cove base, thresholds, ceilings, and water damage in multiple resident rooms and common areas. Several building and maintenance deficiencies were noted that potentially affected residents.

The facility failed to maintain exit discharge gates and exit discharge doors in good repair, affecting residents' safety. The inspection revealed stuck gates, corroded doors, and lack of regular inspections and maintenance since 2019.

The complaint investigation was substantiated. It involved Resident #2 who left the secured unit without staff notification and was missing for approximately 25 to 30 minutes. The facility conducted an internal investigation and identified failures in supervision and alarm monitoring.

The facility failed to ensure the resident environment was free of accident hazards and did not provide adequate supervision and assistance devices to prevent accidents. A resident left the secured unit without notification to staff, resulting in an elopement incident.

The complaint involved allegations of sexual abuse between two residents, one cognitively impaired, where one resident was found naked on top of another. The facility failed to report the incident timely and failed to conduct a full investigation. The complaint was substantiated as evidenced by the deficiencies cited.

The facility failed to ensure timely reporting and thorough investigation of alleged sexual abuse involving residents. The facility also failed to provide appropriate treatment and behavioral health management for residents exhibiting aggressive and sexual behaviors.

The facility failed to provide hot water to residents and laundry areas due to a broken boiler and unrepaired piping, affecting 37 residents and all residents in the building. Multiple interviews and observations confirmed ongoing issues with water temperature and maintenance delays.

The facility was found to have multiple deficiencies related to resident care, activity programming, nutrition, infection control, and environmental safety. Several residents had unmet needs in areas such as activity participation, nutrition monitoring, and safe environment maintenance.

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.

The facility was found to be out of compliance with several provisions of the 2012 Life Safety Code, including issues with access to the kitchen flue, fire resistance ratings, egress door locking mechanisms, discharge from exits, smoking area hazards, cooking facility maintenance, fire alarm system monitoring, sprinkler system maintenance, corridor construction, portable space heater use, and electrical equipment safety. The facility census was 111 residents with a licensed capacity of 154.

The facility was found to have multiple deficiencies including failure to deliver mail timely on weekends, inadequate notice of transfers and discharges, incomplete pain management documentation, insufficient infection control practices, and issues with pressure ulcer care and food safety.

The facility failed to have an Emergency Preparedness plan including temperature monitoring and staff training, and did not meet multiple Life Safety Code requirements including fire barriers, emergency lighting, fire alarm systems, sprinkler systems, smoking regulations, and electrical equipment safety.

The facility was found to have multiple deficiencies related to resident care, including issues with nutrition, medication management, skin integrity, infection control, and fall prevention. Several regulatory requirements were not met, resulting in citations and a plan of correction.

The facility failed to meet several Life Safety Code requirements including fire resistance ratings, exit discharge clearance, emergency lighting, sprinkler system maintenance, smoke barriers, electrical system maintenance, and emergency preparedness policies. These deficiencies potentially affected residents, staff, and visitors.