Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alpine Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with DMII, hemiplegia, incontinence, impaired mobility, anticoagulation therapy, and vascular disease developed a Stage IV sacral pressure ulcer that progressed with drainage, odor, slough, eschar, tunneling, and exposed bone, later requiring hospital transfer and treatment for osteomyelitis. The record showed delayed weekly skin sweeps, missed wound dressing changes, and gaps in documented wound care, while staff and the DON described a skin-check process that was not completed within the expected timeframe.
PASRR Level I screenings were not completed or updated for multiple residents with MI-related diagnoses, including depression, anxiety, PTSD, and alcohol abuse. Several residents had psychotropic meds, behavioral concerns, and care plan focus areas tied to mental health needs, yet their PASRRs did not mark MI or suspected MI, or were not updated when new diagnoses were added. The DON stated the facility had no designated individual to screen, verify, update, or refer PASRRs for Level I or Level II completion.
The facility failed to maintain infection control practices when hand hygiene was not offered to residents during meal delivery, laundry staff handled soiled items without appropriate PPE practices, and a resident with COPD and oxygen use had respiratory equipment that was not properly dated or maintained. Surveyors observed unlabeled nebulizer tubing, an old date on the nasal cannula tubing, and staff uncertainty about weekly tubing changes and respiratory equipment care.
Resident council meetings were not documented as required, and the facility could not show that grievances raised by residents were logged or resolved. Residents said they were unsure who the Grievance Official was, that the role changed often without notice, and that concerns were met with only a vague promise to look into them. Leadership interviews showed the AD had no resident council minutes, had not filed a grievance for a missing-money issue, and the SSD had not been informed of concerns discussed in council.
Unsafe and unclean resident rooms and laundry area: Surveyors observed multiple resident rooms with broken or missing furniture, peeling paint, holes in doors and walls, cracked or missing floor tiles, stained and discolored surfaces, and bathrooms with feces, urine odor, standing water, and clogged toilets. The laundry room also had standing water and debris blocking the drainage channel behind the washers, and staff and leadership acknowledged recurring backups, incomplete reporting of maintenance issues, and uncertainty about who cleaned IV and tube feeding pumps.
Failure to Implement Grievance Process: A resident council grievance process was not followed, and grievances raised in council were not documented, investigated, or resolved as reflected in six months of meeting minutes reviewed. A resident said the Grievance Official changed often and residents only received vague responses like “We will look into it,” while the AD, Social Services, and NHA gave inconsistent accounts of how grievances were handled and documented.
Three cognitively intact residents experienced lapses in ordered controlled and scheduled medications due to failures in timely prescribing, refill requests, and coordination with the pharmacy. One resident with a right leg fracture reported severe pain (9/10) after multiple missed oxycodone-acetaminophen doses documented on the MAR, while notes indicated the drug was on order or not on site and a new script was pending. Another resident with a tracheostomy and neurologic sequelae communicated ongoing pain and concern about her pain medication, yet her MAR showed four consecutive missed oxycodone-acetaminophen doses with no corresponding progress notes. A third resident with epilepsy, anxiety, and depression missed all scheduled clonazepam doses on one day, with documentation repeatedly stating the facility was awaiting pharmacy delivery. Interviews with an LPN, the pharmacist, pharmacy staff, and the DON revealed that low-count warnings, emergency kit access, and on-call prescriber options existed but were not effectively used to prevent these medication gaps.
A resident with diagnoses including bipolar disorder with psychotic features, major depressive disorder, anxiety disorder, epilepsy, and alcohol abuse was not referred to the State Mental Health authority for Level II PASRR. The PASRR only identified substance abuse as the MI, and the DON stated the facility had no designated staff member to screen, verify, update, or refer PASRRs for Level I or Level II.
A resident with major depressive disorder and antidepressant therapy had no depression care plan documented, and the CRD confirmed the omission. Two residents reviewed for smoking also lacked timely or effective smoking care planning: one was observed smoking with cigarettes on his person despite a care plan stating smoking materials were to be kept by staff, and another was observed smoking independently before a smoking-specific care plan was created. Interviews with the CRD and DON confirmed staff knew residents should not keep cigarettes or lighters on them and that one resident had signed smoking consent showing she smoked, but the care plan had not been completed.
Failure to provide nail care for residents needing ADL assistance. A resident with mildly impaired cognition had soiled, long fingernails, broken nails hanging on the nail bed, and stated staff did not cut his nails. Another resident with diabetes and skin issues was observed with long, soiled toenails and toe wounds, with records showing prior podiatry debridement but no later podiatry follow-up found. A third resident was observed with long fingernails on a contracted hand, while staff gave inconsistent responses about who was responsible for nail care and the DON stated CNAs do not cut toenails but can cut fingernails.
Incomplete skin sweeps and skin integrity findings were identified for three residents. One resident had a documented discoloration under the eye, while two residents had only one weekly skin sweep documented with no further entries. During an observation, an RN/UM found abnormal skin integrity in one resident’s breast and abdominal folds, and a resident reported a sore bottom and discomfort when sitting in a wheelchair.
Two residents were not protected from smoking-related accident hazards. One resident with multiple serious diagnoses was observed with cigarettes hidden on his person and a CNA lit his cigarette, while no smoking evaluation was completed despite a care plan noting staff should keep smoking materials. Another resident was observed smoking independently, had no smoking documentation in the initial care plan, and the smoking-specific care plan was added only after the observation. Staff and the DON confirmed smoking assessments were not completed and that residents should not keep cigarettes or lighters in their possession.
Ineffective Pest Control Management: A resident stated that rooms had pests and help was needed to keep bathrooms and rooms clean. A CNA said bug sightings were not being entered in the bug book, and the RMD stated the pest log was not being used as it should be, live bugs were still being found throughout the building, and room round audits were not being completed or entered into the electronic reporting system. Surveyors observed a broken, overflowing toilet with flying pests in one room and live spiders in the East Wing hallway and exit area.
Delayed Skin Checks and Missed Wound Care for Resident With Stage IV Sacral Ulcer
Penalty
Summary
The facility failed to ensure accurate skin evaluations were completed in a timely manner for a resident with significant medical complexity, including traumatic subarachnoid hemorrhage, type 2 diabetes mellitus, hemiplegia and hemiparesis, incontinence, impaired mobility, anticoagulation therapy, peripheral vascular disease, and a worsening sacral pressure ulcer. The resident developed a Stage IV pressure ulcer to the sacrum that was documented as acquired in-house, with measurements, drainage, odor, slough, eschar, erythema, and later tunneling and exposed bone noted in the record. The resident was ultimately transferred to the hospital and later discharged with diagnoses including sacral decubitus ulcer Stage IV, acute coccygeal abscess with underlying osteomyelitis, and ulcerations of both ankles with underlying osteomyelitis. Record review showed the resident’s weekly skin checks were not completed on time. The Treatment Administration Record also showed missed wound dressing changes in March and no documented wound care from 4/15/2026 through 4/19/2026 despite ongoing wound treatment orders. The skin issue record documented repeated evaluations of the sacrum over several weeks, including worsening findings such as moderate seropurulent exudate, odor, saturated dressings, and progression to eschar and later smaller measurements with continued drainage. The resident’s care plan included interventions for actual wounds, incontinence, and skin breakdown risk, but the record also showed no care plan for prevention of skin breakdown prior to 3/30/2026. Interviews with nursing staff and leadership showed the weekly skin sweep process depended on staff reviewing due evaluations in the electronic record, with overdue assessments turning red in the dashboard. The DON stated skin sweeps should be done within 24 hours of when they are due and acknowledged that the resident’s skin sweeps from 02/28, 3/07, 3/14, and 3/21/2026 were created and locked on 3/23/2026, which was identified as an issue. The facility policy stated weekly and PRN skin checks were to be completed once a week, on admission or readmission, and that a new area of impairment should have the appropriate skin grid initiated within 8 hours.
PASRR screenings were not completed or updated for residents with mental health diagnoses
Penalty
Summary
The facility did not complete and/or update PASRR Level I screenings for six residents with qualifying mental health diagnoses or related findings. Record review showed residents had diagnoses including major depressive disorder, recurrent depression, PTSD, anxiety disorder, generalized anxiety disorder, and alcohol abuse with intoxication, along with psychotropic medication use documented in MDS assessments, care plans, and physician orders. For several residents, the PASRR Level I screens did not mark diagnoses under Section A for MI or suspected MI, including residents with depression, anxiety, PTSD, and related behavioral or psychotropic medication needs. Specific examples included a resident with recurrent depressive disorders, PTSD, anxiety, and alcohol abuse whose PASRR did not mark MI or suspected MI; a resident with major depressive disorder and sertraline orders whose PASRR did not mark MI or suspected MI; a resident with major depressive disorder and generalized anxiety disorder whose PASRR did not mark MI or suspected MI; a resident with depression, anxiety, and newly identified PTSD whose PASRR was not updated to reflect the new diagnosis; and a resident with anxiety disorder and major depressive disorder whose PASRR marked anxiety but omitted depression. During interview, the DON stated the facility did not have a designated individual to screen, determine accuracy, update, and/or refer PASRRs for Level I or Level II completion.
Infection Control Failures With Hand Hygiene, Laundry PPE, and Respiratory Equipment
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program in multiple areas. During lunch tray delivery observation, hand hygiene was not offered to residents in rooms 20A, 21B, 22B, 23A, 24A, 24B, 25A, 26A, 26B, and 28B, and hand wipes were not observed on the trays. In the laundry room, staff handling soiled laundry stated they used outdoor work gloves, threw the gloves in the washing machine to clean them, and usually did not wear gowns while handling laundry. The laundry aide also stated he held soiled laundry away from his clothing and separated laundry in red bags, with special handling for C-diff or bed bug items, but no laundry process policy was provided before survey exit. The facility also failed to follow infection control practices related to respiratory equipment for a resident with COPD, emphysema, pleural effusion, and oxygen use. The resident stated staff had not changed the nasal cannula, and surveyors observed the nasal cannula tubing labeled 11/10. The resident’s TAR showed weekly completion entries for nebulizer setup and tubing changes, but when the resident’s nebulizer was observed, the tubing was lying on the nightstand next to urinals with no date on it, and the only date found was on a bag hanging from the nightstand handle dated 10/20/2025. The UM stated the respiratory therapist did not come every week and that the order in the MAR/TAR related to nebulizer tubing, while the DON stated oxygen and nebulizer tubing should be changed weekly and properly dated.
Resident Council Grievances Not Documented or Tracked
Penalty
Summary
The facility failed to ensure resident council meetings were documented as required for six of six months of resident council minutes requested, and it could not demonstrate that grievances voiced during resident council meetings were acted upon. A review of the grievance log from June 2025 to December 2025 did not reveal any entries from Resident Council. During the resident council meeting on 1/7/2026, members stated they were not sure who the Grievance Official was, that the Grievance Official changed frequently without notice, and that staff did not discuss the rationale behind unresolved issues, instead responding only that they would look into it without resolution. Interviews with facility leadership showed inconsistent understanding of the grievance process and a lack of documentation. The NHA stated the activities director had no documentation of resident council minutes and that the expectation was for the activities director to document what occurred on the minutes form. The AD stated she had not filed a grievance when a resident was missing money and investigated the issue herself, later acknowledging that a grievance should have been filed and documented on the grievance form. The SSD stated grievances should be logged and resolved within 72 hours if possible, but she did not participate in resident council meetings and had not been informed of concerns discussed there. The facility policy required residents to be informed of the grievance process, the Grievance Official, and how to file concerns, and required the resident council to be reminded of the Grievance Officer and concern process at least annually.
Unsafe and Unclean Resident Rooms and Laundry Area
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents because multiple resident rooms and the laundry area had damaged, uncleanable, or unsafe conditions. During observations, surveyors found dresser drawers off track or missing, peeling paint, broken furniture, holes in doors and walls, missing and cracked floor tiles, separated cove base exposing drywall, stained and discolored surfaces, and bathrooms with brown-stained towels, plunger bags missing, and toilets containing toilet paper and feces. Several rooms also had water on the floor, standing water, wet walls, urine odor, and bathtubs or toilets with visible buildup or discoloration. The report also documented repeated plumbing and drainage problems affecting resident bathrooms and the laundry room. One resident stated the bathroom backed up occasionally, and the Housekeeping Director said the water buildup in a bathtub could have been from a drainage line backup and that toilets back up occasionally. In another room, water was leaking from the bathroom into the resident room, with standing water in the bathroom and wet drywall and baseboards. Other observations included puddles at the base of toilets, stained flooring, clogged toilets, and a bathtub full of brown-colored water. In the laundry facility, surveyors observed standing water with debris in the drainage channel behind the washing machines, with the debris blocking drainage on one side. On a later observation, the drainage canal remained blocked and full of dirty water. Staff stated the drainage channel overflowed occasionally, and the DON said she did not know who cleaned the IV and tube feeding pumps. The Maintenance Director and Regional Maintenance Director stated staff were expected to report issues in the electronic maintenance system, but not all issues were being reported, room audits were not being completed, and multiple areas identified during the tour were acknowledged as needing repair.
Failure to Implement Grievance Process
Penalty
Summary
The facility failed to implement its grievance process and did not ensure resident grievances raised through Resident Council were received, investigated, and resolved or discussed for six of six months of resident council meeting minutes reviewed. A resident stated the residents were not sure who the Grievance Official was because the person changed and they had to look at a paper on an office door to find out the current person. The resident also stated staff never discussed the rationale behind unresolved issues and that the residents repeatedly received the response, “We will look into it,” without any resolution. During interviews, the NHA stated the activities director had no documentation of resident council minutes and that the expectation was for the activities director to document what occurred during resident council meetings. The Activities Director stated she had not filed a grievance when a resident was missing money and had investigated the issue herself, later acknowledging that she should have filed a grievance and documented it on the grievance form. Social Services stated grievances are logged and sent to the appropriate department, but she did not participate in resident council meetings and had not been informed of concerns discussed there. The NHA stated grievances raised during resident council would be initiated by staff if present, then handled through Social Services, documented on the grievance form, resolved by the appropriate department, and brought back to the resident, with unresolved issues discussed in IDT meetings and, if needed, QAPI.
Failure to Ensure Timely Availability and Administration of Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely provision of ordered controlled substances and other scheduled medications for three residents, despite clear evidence of ongoing pain and anxiety and existing physician orders. One resident with a displaced bimalleolar fracture of the right lower leg, cognitively intact with a BIMS score of 15, reported pain at 9/10 and stated she had not received her prescribed pain medication during the night or that morning. Her MAR for oxycodone-acetaminophen 10-325 mg every 6 hours showed multiple missed doses on several days, coded as “other/see nurse notes,” while concurrent pain monitoring entries documented pain scores of 8 on multiple shifts. Progress notes documented that a new prescription was needed, that the medication was on order or not on site, and that the provider was aware, but the resident continued to experience pain without receiving the ordered narcotic until a new order for a different strength was written later in the day. Another resident with an acquired tracheostomy, dysphagia, and other neurologic sequelae, cognitively intact with a BIMS score of 13, communicated pain in her left arm and back by writing and nodding. She indicated concern about a lapse in her pain medication and activated her call light. The assigned LPN stated that pain medication had been given “not too long ago” and that the resident was not due again until 1:00 p.m. However, the MAR for oxycodone-acetaminophen 10-325 mg every 4 hours showed that on one date, four consecutive scheduled doses (1:00 a.m., 5:00 a.m., 9:00 a.m., and 1:00 p.m.) were not administered and were coded as “other/see nurse notes.” When nurses’ progress notes for the relevant period were requested, none were available for this resident, despite the missed doses and the resident’s care plan directing staff to administer pain medication and observe for effectiveness. A third resident with epilepsy, type 2 diabetes, anxiety disorder, and major depressive disorder, also cognitively intact with a BIMS score of 15, had an order for clonazepam 0.5 mg four times daily for anxiety. During a medication pass, the assigned LPN reported that she was able to administer the clonazepam that day but had been unable to do so the previous day because there was no medication available, requiring a call to the pharmacy for a refill. The MAR documented that all four scheduled clonazepam doses on that date were not administered and were coded as “hold/see nurse notes,” while progress notes repeatedly stated that the facility was “waiting on pharmacy to deliver” and “awaiting from pharmacy,” including after pharmacy notification that delivery would occur on the next run. Interviews with the consultant pharmacist, pharmacy representatives, and the DON confirmed that narcotic and controlled substance prescriptions required valid orders and timely refill requests, that emergency supplies could be accessed under certain conditions, and that low-count warnings existed on medication cards, but these mechanisms were not effectively used to prevent lapses in medication availability and administration for the affected residents. For the resident with the right leg fracture, pharmacy staff reported that on one date the physician telephoned in an order for a three-day supply of oxycodone-acetaminophen 10-325 mg, explaining that a telephone order could only be filled for three days, and that there were no current orders visible after that supply. A pharmacy representative later confirmed that another three-day supply was called in and that an electronic order for a month’s supply had been received but only a three-day supply would be sent until the order was clarified. For the resident with the tracheostomy, a customer service technician stated that a prescription from a pain management provider was dated in mid-December but was not faxed from the facility until the first of the following month and could not explain why the resident missed medications on that date despite having a prescription. The DON described the facility’s process for nurses to request narcotic refills and contact physicians when no refills remained, and acknowledged unawareness of a red warning column on blister packs intended to alert nurses to refill needs, while the facility’s written policy outlined requirements for valid controlled substance prescriptions, emergency verbal authorizations, and use of the emergency supply kit, which were not effectively implemented to ensure uninterrupted access to ordered controlled medications for these residents.
Failure to Refer Resident With Serious Mental Illness for Level II PASRR
Penalty
Summary
The facility did not ensure that the appropriate staff member referred Resident #7, who had serious mental disorder diagnoses, to the State Mental Health authority for Level II PASRR. Resident #7’s admission record showed an original admission date of 11/27/2025 and diagnoses including epilepsy, anxiety disorder, latent syphilis, bipolar disorder with psychotic features, major depressive disorder, and alcohol abuse with intoxication. A review of Resident #7’s PASRR dated 01/27/2025 showed that in Section A, MI or suspected MI, substance abuse was the only mental illness checked. On 01/08/2026 at 1:00 p.m., the DON stated the facility did not currently have a designated individual to screen, determine accuracy, update, and/or refer PASRRs for Level I or Level II. The DON also stated Resident #7 did not have behavior issues. The facility policy titled, PASSR-Requirements for Completion Pre-admission Screening & Resident Review, effective August 2025, stated that PASRR screening is required prior to admission for all individuals and applies to all new admissions into a Medicaid certified nursing facility, including private pay, Medicare, and Medicaid admissions regardless of payer source.
Care plans were not initiated or implemented for depression and smoking needs
Penalty
Summary
The facility did not ensure a care plan was initiated for a resident with a mental health diagnosis. The resident was admitted with major depressive disorder, recurrent, unspecified, and the annual MDS dated 12/22/2025 showed antidepressant use under high-risk drug classes. Physician orders in January 2026 included Sertraline Hydrochloride 50 mg by mouth in the afternoon for depression. Review of the resident’s care plan showed no documentation of interventions or a focus area related to the major depression diagnosis. During interview, the CRD confirmed the resident did not have a care plan for depression and stated that if a resident is receiving medication for depression, it should be included in the care plan. The facility also did not ensure smoking care plans were initiated and/or implemented for two residents reviewed for smoking. One resident was observed self-propelling to the smoking area during designated smoking time and was seen taking a cigarette from his lap while a CNA lit it; the CNA was not observed providing the cigarette from the facility’s designated box. The resident was also observed with the bottom of a cigarette box visible underneath his shirt. His care plan identified him as a current smoker and included interventions such as informing him of the smoking policy and keeping smoking materials with staff, but staff interviews confirmed residents were not supposed to have cigarettes on them and that this resident had cigarettes with him. A second resident was observed smoking independently in the patio during designated smoking time. Her initial care plan contained no smoking-related documentation, although later a smoking-specific care plan was created on 1/8/26. Admission documentation did not identify her as a smoker, but subsequent progress notes and a smoking safety acknowledgement indicated she smoked and had declined cessation education. The CRD stated she did not know the resident smoked before 1/7/26 and acknowledged the admission evaluation did not identify her as a smoker. The DON stated residents should not have lighters or cigarettes on them and confirmed the resident had signed a smoking consent showing she smokes, but did not have an explanation for why a smoking care plan was not completed.
Failure to Provide Nail Care for Residents Needing ADL Assistance
Penalty
Summary
The facility failed to provide nail care as part of assistance with activities of daily living for residents who required help with personal hygiene. Resident #21 was observed with soiled, long fingernails, and later several nails were broken and hanging on the nail bed. The resident stated the facility does not cut his nails but wished it would. The resident had diagnoses including COPD, muscle wasting and atrophy, and type 2 diabetes mellitus without complications, and the MDS showed a BIMS score of 11 with mildly impaired cognition and a functional ability level indicating substantial or maximal assistance for personal hygiene. The care plan included an ADL performance deficit with personal hygiene set up as the intervention, and CNA task records showed repeated entries of no nail care across multiple dates with no other dates marked for nail care during the reviewed period. Resident #43 was observed with long, soiled toenails and wounds on toes 2 and 3 of the right foot. The resident reported podiatry was supposed to come monthly but had not seen him in a while. The resident had diagnoses including other specified mononeuropathies of bilateral lower limbs, cellulitis, muscle wasting and atrophy, and type 2 diabetes mellitus without complications. The MDS showed a BIMS score of 15 and the functional abilities section for personal hygiene was not completed. Progress notes showed the resident injured the right fifth toe in November 2025, with the toenail noted to be bleeding underneath, long, and loose, and podiatry later debrided the toenails and recommended ongoing routine debridement. No additional podiatry notes were found after that visit. Resident #5 was observed with long fingernails on a contracted left hand during a skin sweep assessment. Staff stated that the Activities Director or CNAs can clip residents’ nails, and a CNA identified nail care as a CNA task under the nail care tab. Interviews with the SSD and DON showed that nursing staff should handle fingernail care, CNAs do not cut toenails, and residents needing nail care can be added to the podiatry list. The SSD also stated there was a binder for ancillary services, but it contained nothing when checked, and no policy and procedure related to nail care was received by the end of survey.
Incomplete Skin Sweep Evaluations and Unreported Skin Integrity Findings
Penalty
Summary
The facility did not ensure weekly skin sweep evaluations were completed for three residents. Resident #5 had weekly skin sweeps documented on 12/06/2025, 12/18/2025, and 01/07/2026, and the 12/18/2025 sweep noted a skin impairment under the right eye with discoloration. Resident #13 had a weekly skin sweep documented on 12/06/2025, with no further skin sweeps documented afterward. Resident #36 also had a weekly skin sweep documented on 12/06/2025, with no further skin sweeps documented afterward. During an interview, Resident #13 stated her bottom was sore and that sitting in her wheelchair for an extended time made her feel like her bottom hit the springs of the bed under the mattress. During an observation with the RN/UM and CNA, Resident #36 was found with skin integrity concerns, including glistening red discoloration in the breast folds and abdominal folds with a white-yellow cottage cheese-like substance present. The RN/UM stated this was a positive finding and that the findings would be documented. The DON stated the expectation was for nurses to perform daily skin sweep evaluations and document and report any findings to the provider and, if appropriate, the resident representative.
Smoking Safety and Care Planning Deficiencies
Penalty
Summary
The facility did not ensure residents were free from accident hazards related to smoking for two residents reviewed. Resident #34, who had diagnoses including metabolic encephalopathy, prostate cancer with bone metastasis, muscle wasting and atrophy, unsteadiness on feet, and alcohol abuse, was observed self-propelling to the smoking area during designated smoking time. During the observation, the resident took a cigarette from his lap and a CNA lit it, and a cigarette box was seen coming out from underneath his shirt. The resident’s care plan identified him as a current smoker and stated smoking materials were to be kept by facility staff, but no smoking evaluation or assessment was completed. Resident #23 was observed smoking independently in the patio during designated smoking time. The resident’s diagnoses included endocarditis, lack of coordination, muscle wasting and atrophy, pyogenic arthritis, and discitis. The initial care plan contained no smoking-related documentation, and a smoking-specific care plan was not created until after the observation. The admission nursing note did not document that the resident was a smoker, although later progress notes and psychiatry notes identified the resident as a smoker and documented smoking cessation education that was declined or that the resident had no desire to quit. Interviews with staff and leadership confirmed that smoking evaluations and assessments were not completed for either resident. The CNA stated residents were not supposed to have cigarettes on them, but she knew of residents who did and did not report it to management. The DON confirmed residents should not retain lighters or cigarettes in their personal possession and stated staff should confiscate smoking materials if aware the resident had them. The facility’s smoking policy required smoking materials to be labeled and kept in a secure location, prohibited residents from retaining smoking materials in their personal possession, and directed that smoking care plans be initiated upon admission and reviewed at minimum quarterly and with changes in condition.
Ineffective Pest Control Management
Penalty
Summary
An effective pest control management system was not maintained in one wing and in one room of the facility. During an interview, a resident stated that the rooms had pests and that help was needed to keep the bathrooms and rooms clean. A CNA stated that if bugs were seen, the NHA or DON would be told, but the bug book was not used to report pest sightings. The Regional Maintenance Director stated that the pest log was not being utilized as it should be, live bugs were still being found throughout the building, room round audits were not being done, and the required information was not being entered into the electronic reporting system. During observation with the Regional Maintenance Director, room [ROOM NUMBER] was noted to have a broken and overflowing toilet with pests flying, and the East Wing exit area had live spiders on the ceiling and in the hallway leading to the exit. Review of the contracted pest control company’s Service Inspection Report from 5/2025 to 1/2026 showed multiple sightings and treatments for rodents and pests. Review of the facility’s Pest Control policy dated 8/2024 stated that the facility would strive to protect residents, staff, and visitors from insects and other pests through contracts with outside pest control agencies and would evaluate effectiveness of services and contact the agency if additional services were needed.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saint Petersburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bay Pointe Nursing Pavilion | 1.4 mi | ★★★★★ | 2 | 0 |
| Boca Ciega Center | 2.1 mi | ★★★★★ | 1 | 0 |
| Addington Place At College Harbor | 2.2 mi | ★★★★★ | 0 | 0 |
| Golfview Nursing Center | 2.2 mi | ★★★★★ | 2 | 0 |
| Pinellas Point Nursing And Rehab Center | 2.3 mi | ★★★★★ | 0 | 0 |
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