Inspection Reports for
Alpine Meadow Rehab & Nursing

The complaint investigation found that laboratory results for a resident were not promptly communicated to the provider, delaying treatment. Observations and interviews revealed inadequate hand hygiene practices during meal delivery, increasing infection risk.

The facility failed to promptly notify the ordering physician of laboratory results for one resident, causing a delay in antibiotic treatment. Additionally, the facility did not implement proper infection prevention and control practices, specifically failing to perform hand hygiene when delivering lunch trays between multiple resident rooms.

The investigation was complaint-driven based on allegations from residents 1 and 11 regarding inappropriate touching and abuse by CNA 3. Resident 1 reported attempted sexual abuse, and resident 11 reported inappropriate physical contact. The facility suspended the CNA and conducted an internal investigation. Some allegations were not reported timely to authorities, and some were not thoroughly investigated.

The facility failed to ensure residents were free from abuse, with substantiated allegations of inappropriate touching by a Certified Nurse Assistant (CNA). Additionally, the facility did not timely report all abuse allegations and failed to thoroughly investigate some allegations. Medication administration errors were also identified, with insulin doses given significantly late for three residents.

The complaint investigation focused on allegations that the facility failed to timely report and investigate an unwitnessed fall with fracture, failed to provide appropriate respiratory care, had excessive medication errors, and failed to maintain infection control during a COVID-19 outbreak. The investigation substantiated these issues with multiple residents affected, including Resident 28's fall and fracture, respiratory care deficiencies for Residents 1 and 18, medication errors affecting Residents 1, 4, 20, and 35, and infection control lapses affecting Residents 4 and 35.

The facility failed to timely report and investigate an unwitnessed fall resulting in a fracture, did not ensure respiratory care was provided per professional standards, had a 25% medication error rate including late and incorrect doses, failed to maintain infection control during a COVID-19 outbreak, and did not store or handle food according to professional standards.

The investigation was complaint-related due to concerns about infection control during a COVID-19 outbreak. The complaint was substantiated with findings of improper PPE use, cross-contamination risks, and delayed COVID-19 testing.

The facility failed to maintain an effective infection prevention and control program during a COVID-19 outbreak. Staff did not properly dispose of PPE, failed to wear eye protection in COVID-positive resident rooms, did not bag or identify meal trays from COVID-positive rooms, and a symptomatic resident was not promptly tested for COVID-19.

The complaint investigation revealed that a resident choked on food that was not mechanically altered per physician orders, requiring emergency medical attention. Additional residents also received incorrect diet textures. The facility was found to have failed in implementing CMS recommended practices for diet preparation, supervision, and monitoring, leading to an Immediate Jeopardy designation.

The facility failed to ensure that residents received food prepared according to their prescribed mechanically altered diets, leading to an Immediate Jeopardy situation where a resident choked and required emergency medical intervention. Multiple residents received incorrect diet textures, and the facility lacked adequate staff training and oversight to prevent these errors.

The complaint involved allegations that Resident 2 attempted to trip other residents and kicked wheelchairs, causing other residents to feel unsafe. The facility reported the initial incident but failed to submit a follow-up investigation report to the State Survey Agency within the required timeframe. The Administrator was unable to provide documentation of a completed investigation.

The facility failed to thoroughly investigate all alleged violations and did not submit the results of investigations to the State Survey Agency within five working days. Specifically, for 2 of 5 sampled residents, the investigation of abuse allegations was incomplete and not reported as required.

The facility was found deficient in ensuring adequate nutritional interventions for a resident with significant weight loss, timely pharmacist recommendations communication and action, provision of thickened liquids as ordered, and proper food service practices including uncovered desserts during meal delivery.