Inspection Reports for Alpine Nursing Home Inc
557 WEAVER HILL ROAD, RI, 02816
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
85% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
97% occupied
Based on a March 2025 inspection.
Census over time
Inspection Report
Plan of Correction
Census: 58
Capacity: 60
Deficiencies: 4
Mar 27, 2025
Visit Reason
A recertification and complaint survey was conducted from 3/24/2025 through 3/27/2025 to determine compliance with 42 CFR Part 483 for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were identified related to nutritional adequacy of menus, food procurement and safety, and sanitation in the kitchen. The facility failed to provide standardized recipes with nutritional content, failed to store and prepare food according to professional standards, and had improperly labeled spray bottles and uncovered trash receptacles. Emergency preparedness and life safety code surveys found the facility in compliance.
Deficiencies (4)
| Description |
|---|
| Facility failed to provide a dietary menu that meets nutritional needs of residents in accordance with established national guidelines; diet manual lacked required nutritional guidelines and standardized recipes were not on file. |
| Facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety; spray bottles were incorrectly labeled or unlabeled. |
| Accumulation of grease on the rim of the hood over the stove; trash receptacles uncovered and not in continuous use. |
| Cooling logs showed split pea soup did not meet temperature requirements at 2 hours; corrective actions were taken immediately. |
Report Facts
Capacity: 60
Census: 58
Dates of survey: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Interviewed during survey and acknowledged deficiencies related to food safety and sanitation |
Inspection Report
Plan of Correction
Deficiencies: 0
May 28, 2024
Visit Reason
An off-site desk audit was conducted on May 28, 2024, to review all previous deficiencies cited on April 15, 2024.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 23, 2024
Visit Reason
An off-site desk audit was conducted on April 23, 2024, to review all previous deficiencies cited on March 27, 2025, and verify correction.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 59
Capacity: 60
Deficiencies: 7
Apr 15, 2024
Visit Reason
A Recertification Survey and complaint investigation survey were conducted at Alpine Nursing Home from 4/10/2024 through 4/15/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were cited related to accuracy of assessments, comprehensive care plans, respiratory/tracheostomy care and suctioning, trauma-informed care, competent nursing staff, resident records confidentiality, and infection prevention and control. The facility failed to accurately reflect residents' status, provide professional standards of care, ensure trauma-informed care, maintain medical records, and properly implement infection control practices.
Complaint Details
The visit included a complaint investigation as indicated by the initial comments stating a recertification survey and complaint investigation survey were conducted. Specific complaint details or substantiation status are not explicitly stated.
Deficiencies (7)
| Description |
|---|
| Accuracy of Assessments - The assessment did not accurately reflect the resident's status for hand contractures. |
| Comprehensive Care Plans - Services provided did not meet professional standards of quality for apical pulse measurement. |
| Respiratory/Tracheostomy Care and Suctioning - Facility failed to provide respiratory care consistent with professional standards for residents using oxygen and nebulizers. |
| Trauma Informed Care - Facility failed to ensure trauma survivors received trauma-informed care and assessments were not completed for identified residents. |
| Competent Nursing Staff - Facility failed to ensure nursing staff had appropriate competencies and skills for nursing and related services. |
| Resident Records - Facility failed to maintain accurate, complete, and confidential medical records for residents. |
| Infection Prevention and Control - Facility failed to conduct appropriate infection control practices including PPE use and hand hygiene for staff caring for COVID-19 positive residents. |
Report Facts
Deficiencies cited: 7
Resident census: 59
Total capacity: 60
COVID-19 outbreak resident count: 12
Inspection Report
Follow-Up
Deficiencies: 0
Apr 7, 2023
Visit Reason
A follow-up to a previous Recertification survey was conducted at this facility.
Findings
All previous deficiencies were corrected and no new deficiencies were identified.
Inspection Report
Annual Inspection
Deficiencies: 3
Mar 17, 2023
Visit Reason
A recertification survey and complaint investigation survey were conducted at Alpine Nursing Home from 03/14/2023 through 03/17/2023 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a state licensure and emergency preparedness survey.
Findings
Deficiencies were cited related to accident hazards and nutrition/hydration status. One resident fell during transfer without use of a gait belt resulting in a fracture. Another deficiency involved failure to maintain acceptable nutritional parameters for a resident with severe weight loss. No Life Safety Code deficiencies were identified.
Complaint Details
The complaint investigation was triggered by a facility-reported incident on 03/13/2023 where a resident fell while being transferred from a shower chair to a wheelchair without a gait belt, resulting in a fracture of the right radial styloid process. The complaint was substantiated with findings of deficient resident handling and supervision.
Severity Breakdown
SS=G: 2
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure a resident's environment remained free from accident hazards; resident fell during transfer without use of a gait belt resulting in a fracture. | SS=G |
| Facility failed to maintain acceptable nutritional status for a resident who experienced severe weight loss and inadequate oral intake. | SS=G |
| Facility failed to properly store and prepare food in accordance with professional standards for food service safety, including undated food items and uncovered food trays. | SS=F |
Report Facts
Residents reviewed for falls: 3
Resident weight loss: 33.4
Opportunities for meal intake: 49
Supplement opportunities: 33
Weight loss percentage: 17.3
Weight loss percentage over 1 month: 8.3
Number of undated vanilla shakes: 40
Number of undated milk cartons: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Nursing Assistant | Revealed she transferred resident without gait belt on 3/10/2023. |
| Staff B | Charge Nurse | Interviewed regarding expectation to transfer resident with gait belt and meal supplement procedures. |
| Staff C | Occupational Therapist | Interviewed regarding expectation to transfer resident with gait belt. |
| Director of Nursing Services | Interviewed regarding expectation to transfer resident with gait belt and documentation of meal intake. | |
| Staff D | Certified Nursing Assistant (CNA) | Provided resident weight data during survey. |
| Staff E | Nursing Assistant | Acknowledged pastry on lunch trays was not covered. |
| Food Service Director (FSD) | Acknowledged undated food items and food safety issues during survey. | |
| Dietitian | Interviewed regarding resident weight loss and nutritional interventions. |
Inspection Report
Annual Inspection
Deficiencies: 3
Mar 17, 2023
Visit Reason
A Recertification Survey and Complaint investigation was conducted at Alpine Nursing Home from 03/14/2023 through 03/17/2023 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a State licensure and emergency preparedness survey.
Findings
Deficiencies were cited related to accident hazards and supervision, nutritional status and hydration, and food safety requirements. The facility failed to ensure residents remained free of accident hazards, maintain acceptable nutritional parameters for some residents, and properly store and prepare food according to professional standards.
Complaint Details
The visit included a complaint investigation related to a resident fall during transfer without use of a gait belt, which was substantiated as the facility failed to ensure accident hazards were prevented.
Severity Breakdown
SS=G: 2
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure a resident remained free from accident hazards by not using a gait belt during transfer, resulting in a resident fall and fracture. | SS=G |
| Facility failed to ensure residents maintained acceptable nutritional status, including weight loss and inadequate meal intake documentation. | SS=G |
| Facility failed to properly store and prepare food in accordance with professional standards, including undated food items and uncovered food trays. | SS=F |
Report Facts
Deficiencies cited: 3
Resident weight loss: 33.4
Weight loss percentage: 17.3
Resident weight loss: 14.4
Weight loss percentage: 8.3
Undated food items: 40
Meal intake opportunities: 49
Meal intake less than 25%: 42
Supplement offered: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Nursing Assistant | Revealed she attempted to transfer resident without gait belt |
| Staff B | Charge Nurse | Interviewed regarding expectation of gait belt use and weight audits |
| Staff C | Occupational Therapist | Interviewed regarding expectation of gait belt use |
| Director of Nursing Services | Interviewed regarding expectation of gait belt use and meal intake documentation | |
| Certified Nursing Assistant (CNA), Staff D | Certified Nursing Assistant | Provided resident weight during surveyor's request |
| Food Service Director (FSD) | Food Service Director | Interviewed regarding food storage and safety deficiencies |
Inspection Report
Routine
Deficiencies: 0
Dec 13, 2022
Visit Reason
A Federal Infection Control survey was conducted at Alpine Nursing Home on 12/13/2022.
Findings
No deficiencies were cited as a result of this survey.
Inspection Report
Follow-Up
Deficiencies: 0
Mar 9, 2022
Visit Reason
A follow-up survey to the annual State/Federal survey was conducted at this facility to verify correction of previous deficiencies.
Findings
All former citations were corrected and no new deficient practice was identified during the follow-up survey.
Inspection Report
Re-Inspection
Deficiencies: 8
Feb 4, 2022
Visit Reason
A Recertification Survey and complaint investigation were conducted at Alpine Nursing Home from 01/31/2022 through 02/04/2022 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
The facility was found not in compliance with requirements related to freedom from abuse and neglect, professional standards of care, medication administration, nutrition and hydration, respiratory care, assistive devices, food safety, facility assessment, and infection prevention and control. Multiple deficiencies were identified involving resident care and facility policies.
Complaint Details
The visit included a complaint investigation with ACTS reference numbers 83285, 81699, and 80497. The complaint involved allegations of abuse, neglect, and failure to provide adequate care and infection control.
Deficiencies (8)
| Description |
|---|
| Failure to provide services necessary to avoid pain and emotional distress for Resident ID #53, including inadequate pain assessment and response. |
| Failure to assure services met professional standards related to physician's medication orders for Resident ID #14, including missed doses of Lorazepam. |
| Failure to maintain acceptable nutritional status for Residents ID #9 and #53, including significant weight loss and inadequate monitoring. |
| Failure to ensure respiratory care consistent with professional standards for Resident ID #53, including oxygen therapy without active physician order. |
| Failure to provide special eating equipment and utensils for Resident ID #28, resulting in inadequate nutrition. |
| Failure to store, prepare, distribute, and serve food in accordance with professional food safety standards, including improperly dated and discarded food items and unclean freezer. |
| Failure to conduct and document a comprehensive facility assessment addressing resident population needs and resources. |
| Failure to establish and maintain an infection prevention and control program, including inadequate isolation of COVID-19 positive residents and improper handling of contaminated linens. |
Report Facts
Deficiencies cited: 8
Medication missed: 8
Weight loss: 7.48
Oxygen flow rates: 3
COVID-19 positive residents: 17
Rooms with COVID-19 positive residents: 10
Residents in outbreak: 59
Deaths: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Observed during medication pass and resident care related to pain assessment. | |
| Director of Nursing Services | Director of Nursing (DNS) | Interviewed regarding resident pain and care observations. |
| Director of Nursing Services | Director of Nursing Services | Interviewed about medication administration and oxygen orders. |
| Registered Dietitian | Registered Dietitian (RD) | Interviewed regarding resident nutritional assessments and weight monitoring. |
| Assistant Director of Nursing Services | Assistant Director of Nursing Services (ADNS) | Interviewed regarding resident weight monitoring. |
| Food Service Director | Food Service Director (FSD) | Interviewed regarding food safety and storage deficiencies. |
| Assistant Administrator | Assistant Administrator | Interviewed regarding facility assessment tool. |
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