Above average — CMS composite of the measures below.
The next survey window likely opens around July 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alpine Village Retirement Center during CMS and state inspections, most recent first.
The facility failed to document and offer nonpharmacological treatment options when obtaining consent for psychotropic medications for several residents. A resident with PTSD, anxiety, and depression; a resident with severe cognitive impairment and dementia; and two residents with dementia-related behaviors received antipsychotic, antianxiety, and/or antidepressant medications, and consent forms were completed, but the records did not show that alternate treatment interventions were presented. The DON confirmed the facility had no evidence that these options were provided with the psychotropic medication consents.
Failure to Test Symptomatic Residents for COVID-19: The DON confirmed the facility was not testing all residents with respiratory symptoms for COVID-19 and was relying on physician direction or surveyor request. One resident with dementia, diabetes, and HTN had fatigue, cough, and lethargy before a COVID test was finally obtained; another resident with CAD, HTN, kidney disease, and vascular disease had a prolonged cough, congestion, weakness, and fatigue without evidence of testing; a third resident with severe cognitive impairment, HF, kidney disease, diabetes, and dementia had cough, sore throat, low O2 sat, fever, wheezing, and lethargy before testing was done.
The facility did not employ a Dietary Manager with the required qualifications, as confirmed by both the DM and the Administrator, and the Registered Dietician was not full-time. This affected all residents receiving food service.
A resident with multiple chronic conditions and severe cognitive impairment experienced a fall and subsequently reported ongoing pain in several areas over multiple days. Although the PCP was notified of the initial fall, staff did not update the PCP about the resident's continued pain and changes in condition until the resident was later diagnosed with a rib fracture. The DON confirmed that required notifications were not made in a timely manner.
Two residents with complex medical needs experienced unaddressed weight loss due to the facility's failure to consistently provide prescribed nutritional interventions, such as fortified foods and clear nutritional supplements, as recommended by the RD. Documentation and observations showed that supplements were often not offered or consumed, and meal fortification was inconsistently applied, despite ongoing weight loss.
Staff did not consistently use gloves and gowns as required during high-contact care activities for two residents under Enhanced Barrier Precautions due to open wounds. Despite facility policy and signage, nursing assistants were observed transferring and providing care to residents without proper PPE, including after toileting and while handling linens and positioning residents. The DON confirmed that gloves should have been worn during these activities.
Failure to Inform Residents of Nonpharmacological Options for Psychotropic Medications
Penalty
Summary
The facility failed to fully inform residents and/or their resident representatives by not documenting and offering nonpharmacological treatment options when obtaining consent for psychotropic medications. The deficiency involved 4 of 5 sampled residents, including residents with diagnoses such as dementia, anxiety, depression, PTSD, stroke, and severe cognitive impairment. Facility policies stated that residents and/or representatives would be educated on medications and that consent forms would be completed with new psychotropic orders and dose increases, but the records reviewed did not show alternative nonpharmacological interventions were presented with the consents. Resident 4 was cognitively intact, independent with several activities of daily living, and had diagnoses including diabetes, stroke, anxiety, depression, and PTSD. The resident received aripiprazole, buspirone, fluoxetine, and trazodone, and consent forms were completed for each medication. Resident 25 had severe cognitive impairment, required staff assistance with dressing, toileting, transfers, and hygiene, and had diagnoses of dementia, anxiety, and depression. The resident received bupropion and venlafaxine, and consent forms were completed for both medications. For both residents, the record contained no evidence that nonpharmacological treatment options were documented and offered. Resident 21 had severe cognitive impairment, delusions, and other behaviors 1-3 days weekly, with diagnoses of dementia, anxiety, and depression, and received mirtazapine, citalopram, quetiapine, and lorazepam. Resident 1 had severe cognitive impairment, rejected care, wandered 1-3 days in the prior 7 days, required assistance with hygiene, dressing, and bathing, and received lorazepam and quetiapine for anxiety and behavior disturbance associated with dementia. For both residents, consent forms were present for the psychotropic medications, but there was no evidence that alternative nonpharmacological treatment intervention options were documented and offered. The DON confirmed during interview that the facility did not have evidence that such alternatives were provided when obtaining consent.
Failure to Test Symptomatic Residents for COVID-19
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when it did not test residents for COVID-19 after they developed signs and symptoms of respiratory illness. The facility policy stated that residents should be tested when symptoms such as fever or chills, cough, shortness of breath, fatigue, sore throat, congestion or runny nose, nausea or vomiting, and/or diarrhea were present. During interview, the DON confirmed the facility was not testing all residents with respiratory symptoms for COVID-19 and that some testing was done only at the physician’s direction or after surveyor request. Resident 1 had severe cognitive impairment, dementia, diabetes, and hypertension, and was noted to have fatigue, a nonproductive cough, increased lethargy, and a temperature of 99.1. The resident was not tested for COVID-19 when these symptoms were first documented; a COVID-19 antigen rapid test was not given until after surveyors requested evidence of testing, and the result was negative. The DON confirmed the resident was not tested when the respiratory symptoms were present. Resident 19 had coronary artery disease, hypertension, kidney disease, and vascular disease, and was not up to date on the COVID-19 vaccine. The resident developed a harsh cough, runny nose, chest congestion, coarse lung sounds, weakness, fatigue, and ongoing cough symptoms over an extended period, but there was no evidence of COVID-19 testing during the illness. Resident 26 had severe cognitive impairment, hypertension, heart failure, kidney disease, diabetes, and dementia, and presented with congested cough, sore throat, head and chest congestion, low oxygen saturation of 88%, fever up to 100.5, wheezing, weakness, lethargy, and coarse lung sounds. Although the resident continued to be monitored and later received medications, COVID-19 testing was not performed until after surveyor inquiry, and the DON confirmed the resident was not tested when respiratory illness symptoms were observed.
Failure to Employ Qualified Dietary Manager
Penalty
Summary
The facility failed to employ a qualified Dietary Manager (DM) as required by state regulations. Record review of the Dietary Services Supervisor job description indicated that the DM must meet state requirements. During interviews, the DM confirmed that the necessary education for the position had not been completed, and the Administrator verified that the current DM did not have the required training. Additionally, it was confirmed that the Registered Dietician was not employed full-time at the facility. This deficiency had the potential to affect all 33 residents who received food service from the kitchen.
Failure to Notify PCP of Resident's Ongoing Change in Condition After Fall
Penalty
Summary
The facility failed to ensure timely identification and communication of a resident's change in condition to the Primary Care Provider (PCP) as required by facility policy. After a resident experienced a fall, the PCP was initially notified of the incident. However, over the following days, the resident continued to report ongoing pain in the right hip, groin, thigh, pelvis, and right torso. Despite these persistent complaints and changes in the resident's condition, there was no documented evidence that the PCP was updated about the resident's continued pain or change in status until the resident was seen by the PCP several days later and diagnosed with a right 11th rib fracture. The resident involved had a complex medical history, including anemia, end stage renal disease, dementia, malnutrition, anxiety, depression, and chronic obstructive pulmonary disease, with severely impaired cognition and behavioral symptoms. The failure to notify the PCP of the resident's ongoing pain and refusal of care following the fall was confirmed by the Director of Nursing, who acknowledged that staff did not provide timely updates to the PCP regarding the resident's condition between the initial fall notification and the subsequent diagnosis of a rib fracture.
Failure to Implement Assessed Nutritional Interventions to Prevent Weight Loss
Penalty
Summary
The facility failed to implement and consistently provide assessed nutritional interventions to prevent weight loss for two residents with significant medical conditions. Both residents had documented weight loss and were assessed by the Registered Dietician (RD) to require specific dietary interventions, including fortified foods, nutritional supplements, and planned snacks. Despite these recommendations, documentation and direct observation revealed that the prescribed supplements were frequently not offered, refused, or not consumed, and that fortification of meals was inconsistently applied. For one resident with diagnoses including anemia, end stage renal disease, dementia, and malnutrition, the care plan included fortified foods, protein powder, and clear nutritional supplements at specified meals. However, records showed that the resident did not receive or consume the supplements on numerous occasions over several months. Observations confirmed that the resident did not receive the supplement as recommended during meal service, and the Dietary Manager acknowledged that supplements were not always offered or documented as required. Another resident with severe cognitive impairment and multiple diagnoses, including non-traumatic brain dysfunction and malnutrition, was also assessed to need fortified meals, clear nutritional supplements at noon and evening meals, and snacks three times daily. Documentation indicated that the resident frequently did not receive or consume the supplements, and meal observations showed that fortification and prescribed substitutions (such as half and half instead of milk) were not provided. The Dietary Manager confirmed these interventions were not consistently implemented as ordered.
Failure to Ensure Proper PPE Use During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper use of Personal Protective Equipment (PPE), specifically gowns and gloves, during high-contact care activities for two residents who were under Enhanced Barrier Precautions (EBP) due to open wounds requiring dressings. Facility policy required staff to use PPE during high-contact activities such as dressing, transferring, providing hygiene, changing linens, toileting assistance, and wound care for residents with wounds. Observations revealed that staff did not consistently wear gloves during these activities, despite EBP signage and PPE availability outside the residents' rooms. For one resident with a pressure ulcer and a chronic non-pressure wound, nursing assistants completed toileting care and transferred the resident to bed without wearing gloves, touching the resident's clothing, blankets, and assisting with positioning. For another resident with a pressure ulcer, staff similarly completed toileting care and transferred the resident to bed without donning gloves, then touched linens, pillows, and the resident. The Director of Nursing confirmed that gloves should be worn during all high-contact care activities for residents under EBP.
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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
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Nursing homes near Verdigre
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avera Creighton Care Centre | 10.7 mi | ★★★★★ | 7 | 0 |
| Good Samaritan Society - Bloomfield | 19.7 mi | ★★★★★ | 8 | 0 |
| Plainview Manor | 20.6 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society Tyndall | 29.5 mi | ★★★★★ | 9 | 0 |
| Accura Healthcare Of Neligh | 31.5 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.