Inspection Reports for
Alpine Skilled Nursing and Rehabilitation Center

The complaint investigation included multiple allegations such as failure to respond to discharge requests, unsafe discharge, failure to pay for hotel rooms, failure to provide financial statements, resident elopement, delayed call light response, lack of dignity and respect, unaddressed pain, resident-to-resident altercations including racial slurs, and smoking with oxygen leading to a fire. Several allegations were not substantiated due to lack of evidence.

The investigation included multiple allegations such as failure to respond to discharge requests, unsafe discharge, failure to pay for hotel rooms, failure to provide financial statements, resident elopement, delayed call light response, lack of dignity and respect, unaddressed pain, resident-to-resident altercations including racial slurs, and smoking with oxygen leading to a fire. Several allegations were not substantiated due to lack of evidence. Deficiencies were identified related to resident rights, abuse investigations, care planning, and accident prevention.

The complaint investigation focused on a resident-to-resident verbal altercation involving racial slurs and verbal abuse. The facility failed to investigate and report the abuse properly, and care plans were not updated accordingly. The investigation also included concerns about resident safety related to smoking while on oxygen, which led to a fire incident.

The facility failed to protect residents from racial discrimination and verbal abuse, did not properly investigate and report allegations of verbal abuse, and failed to update care plans after incidents. Additionally, the facility failed to adequately supervise a resident with a history of smoking while on oxygen, resulting in a fire and injury.

The facility was found deficient in multiple areas including failure to protect resident confidentiality, inadequate ambient temperatures in shower rooms, incomplete care plans and wound care documentation, failure to provide timely dental services, improper medication storage including expired medications, failure to post current nursing staffing information, and inadequate infection control practices.

The facility was found deficient in maintaining accurate personnel records, including timely fingerprinting for background checks and tuberculosis screening prior to employee start dates. Additionally, cultural competency training was not completed within the required timeframe for one employee. Corrective actions and monitoring plans were outlined to address these deficiencies.

Complaint #NV00072523 was substantiated for verbal, physical, and emotional abuse by a CNA towards a resident, and for failure to provide timely dietary evaluation and nutritional supplement administration for a resident with a stage four pressure ulcer.

The facility failed to protect a resident from verbal and physical abuse by a CNA who yelled at and threw a pillow at the resident. Additionally, the facility failed to ensure a resident with a stage four pressure ulcer received timely dietary evaluation and administration of a physician-ordered nutritional supplement, Pro-Stat.

The complaint was substantiated. The Housekeeper was terminated on 02/14/2024 for misappropriation of resident funds. The facility conducted an investigation and provided staff training on financial exploitation/misappropriation of resident property.

The facility failed to ensure a resident was free from misappropriation of property when a Housekeeper asked Resident #1 to borrow money. The Housekeeper was terminated for this substantiated allegation, and the resident was reimbursed in full with no mental anguish reported.

The visit was complaint-related, triggered by concerns about informed consent, medication administration, resident grievances, infection control, medication security, documentation of care, and staff training. Substantiation status is not explicitly stated.

The facility failed to obtain informed consent for certain resident care interventions, did not develop complete care plans for multiple residents, failed to ensure timely medication consents and appropriate psychotropic medication use, did not address resident grievances related to missing laundry, left medications unsecured and expired medications in medication carts, failed to document treatment administration records for catheter and G-tube care, left resident information visible on unattended computer screens, and did not provide required communication training to some staff.

The facility was found deficient in several areas including incomplete tuberculosis (TB) testing for employees prior to employment, failure to ensure combustible materials were not stored in high hazard or equipment rooms, failure to protect potable water supply from cross-contamination, and failure to ensure cultural competency training was completed within 30 days of hire for certain employees.

The facility failed to administer medications according to physician's orders for 2 of 7 sampled residents. Specifically, Resident #2 received a lower dose of Calcium Citrate-Vitamin D than ordered, and Resident #3 had a Lidocaine patch applied to the wrong shoulder.

The facility was found to be in substantial compliance with the Emergency Preparedness program but had deficiencies related to Life Safety Code including delayed egress doors requiring excessive force, self-closing doors held open improperly, cooking facility fire protection issues, electrical safety violations including extension cords and broken receptacles, lack of fire drill documentation, and improper storage of oxygen cylinders.

Substandard quality of care was identified including failure to provide scheduled showers to a dependent resident, failure to obtain informed consent for psychotropic medications, failure to protect resident property, failure to update care plans for psychotropic medication use and toileting programs, failure to prevent pressure ulcers, failure to maintain nutrition and hydration, failure to follow oxygen therapy orders, failure to secure medications, failure to properly store food, and failure to protect resident health information.

The facility was found deficient in multiple areas including failure to provide scheduled showers to a dependent resident, lack of informed consent and care planning for psychoactive medications, failure to protect residents' belongings, incomplete bowel and bladder programs for most residents, medication administration errors, unsecured medications and medication carts, failure to monitor significant weight loss and notify dietitians, failure to follow oxygen therapy orders, and failure to maintain food safety standards.

The facility was found deficient in ensuring timely dementia training and cultural competency training for employees. Specifically, 8 of 18 sampled employees lacked timely dementia training and 11 of 18 sampled employees lacked documented evidence of cultural competency training using an approved program.

The complaint investigation included allegations of abuse, neglect, exploitation, and mistreatment involving multiple residents. Some allegations were substantiated, including a deep tissue injury caused by a deflated air mattress during a power outage, verbal and physical abuse among residents, and failure to maintain proper care and monitoring. Other allegations could not be substantiated due to lack of evidence.

The investigation included allegations of abuse, neglect, and mistreatment involving multiple residents. Several allegations were substantiated including a resident left on a deflated air mattress resulting in a deep tissue injury, verbal abuse, and physical altercation between residents. Other allegations could not be substantiated due to lack of evidence. The facility failed to ensure proper care and monitoring of residents, including failure to maintain air mattress inflation during a power outage.

The complaint investigation involved 10 Facility Reported Incidents (FRIs) alleging bruises, fractures, and physical altercations among residents. Some allegations were substantiated, such as resident-to-resident altercations involving physical and verbal abuse, while others could not be substantiated due to lack of evidence.

The investigation included observations, interviews with residents and staff, and clinical record reviews. Multiple allegations of abuse and neglect were investigated, with some substantiated and others not due to lack of evidence. Deficiencies related to resident rights, abuse, neglect, care planning, and failure to update care plans after incidents were identified.

The facility was found to have multiple deficiencies including substandard quality of care related to medication administration, resident rights violations, infection control issues, incomplete care planning, failure to implement bowel and bladder programs, medication errors, and inadequate infection prevention and control practices. The facility also failed to maintain accurate records, conduct proper staff vaccination tracking, and ensure proper PPE use and fit testing.

Complaint #NV00065750 alleging a resident was left in bed all day was substantiated. Other allegations related to falls, neglect, medication administration, misappropriation of funds, resident altercation, and injury of unknown origin were not substantiated due to lack of evidence.

The complaint alleging a resident was left in bed all day was substantiated. Other allegations related to falls, medication administration, misappropriation of funds, resident altercation, and injury of unknown origin were not substantiated due to lack of evidence. The facility was 100% compliant with Healthcare Worker vaccination requirements. Deficiencies unrelated to the complaint were also identified. Additionally, isolated deficiencies causing no harm were found, including failure to assist a resident out of bed, failure to provide discharge notice to the resident and Ombudsman, and failure to update a care plan after a resident fall.

The investigation was complaint-driven, involving six complaints and 36 Facility Reported Incidents (FRIs). Some allegations were substantiated such as resident-to-resident abuse and falls, while others were not substantiated due to lack of evidence.

The investigation included multiple complaints and FRIs, with some allegations substantiated such as resident-to-resident abuse and falls. Several allegations could not be substantiated due to lack of evidence. Deficiencies were found related to resident rights, abuse, neglect, fall risk assessments, and safety.

Complaint #NV00062773 with the allegation a resident's teeth were unbrushed was substantiated. Other allegations including a cut on a resident's chin, body odor, unshaven legs, soiled brief, tube feeding stopped without consent, incorrect admission date, failure to review allergies, verbal and physical abuse allegations were unsubstantiated.

The revisit survey found the facility came into compliance for F686. One complaint regarding a resident's teeth being unbrushed was substantiated. Several other allegations including physical and verbal abuse, body odor, and medication issues were not substantiated. The facility lacked documented evidence of routine oral care, including tooth brushing, for one resident.