Inspection Reports for
Alpine Rehabilitation and Nursing Center
755 East Monroe Street, Little Falls, NY, 13365
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
14.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
184% worse than New York average
New York average: 5.1 deficiencies/year
Deficiencies per year
32
24
16
8
0
Inspection Report
Annual Inspection
Capacity: 60
Deficiencies: 1
Date: Jul 10, 2024
Visit Reason
Abuse reporting documentation deficiency noted.
Findings
Abuse reporting documentation deficiency noted.
Deficiencies (1)
R9-10-803.J — Abuse reporting documentation
Inspection Report
Annual Inspection
Deficiencies: 4
Date: May 3, 2024
Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys from 4/29/2024 to 5/3/2024 to assess compliance with regulatory standards for Alpine Rehabilitation and Nursing Center.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, thoroughly investigating an elopement incident, providing appropriate treatment and care including timely administration of anti-nausea medication, and ensuring food served was palatable and served at appropriate temperatures.
Deficiencies (4)
F 0584: The facility did not ensure a safe, clean, and homelike environment; multiple areas had urine odors, sticky floors, missing tiles, stained ceiling tiles, damaged walls, and cluttered resident rooms.
F 0610: The facility failed to thoroughly investigate an elopement incident involving Resident #37, lacking witness statements and failing to determine how the resident exited the facility.
F 0684: Resident #70 was not provided anti-nausea medications when needed, and emesis, feces, and a full urine bag were visible at the resident's bedside, violating dignity and infection control standards.
F 0804: The facility did not ensure food was palatable, flavorful, and served at appetizing temperatures; residents reported burnt, overcooked, and cold food, including burnt lasagna observed during the lunch meal.
Report Facts
Temperature of lasagna: 152
Urine volume in collection bag: 1200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | Completed Resident Accident/Incident Report and involved in elopement incident investigation | |
| Certified Nurse Aide #4 | Witnessed and assisted in retrieving Resident #37 during elopement incident | |
| Director of Maintenance | Interviewed regarding door malfunction and maintenance related to elopement incident | |
| Director of Nursing | Provided information on elopement investigation and nursing response | |
| Physician #13 | Provided medical orders and statements regarding Resident #70's care and anti-nausea medication | |
| Certified Nurse Aide #10 | Reported resident rooms not maintained in a homelike environment and food complaints | |
| Registered Nurse Unit Manager #15 | Interviewed about urine bag care and resident dignity issues | |
| Assistant Food Service Director #27 | Discussed resident complaints about food quality and efforts to address them | |
| Licensed Practical Nurse #7 | Reported frequent resident complaints about burnt and cold food |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: May 3, 2024
Visit Reason
The inspection was a recertification and abbreviated survey conducted from 4/29/2024 to 5/3/2024 to assess compliance with Medicare and Medicaid regulations and facility licensing requirements.
Findings
The facility was found deficient in multiple areas including failure to provide required Medicare notices to residents, inadequate investigation of an elopement incident, failure to provide appropriate treatment and care including medication administration, unsafe medication storage and labeling, poor food quality and kitchen sanitation, inadequate infection control practices, and ineffective pest control.
Deficiencies (10)
F 0582: The facility failed to provide required Medicare Non-Coverage and Advanced Beneficiary Notices to 2 residents when Medicare Part A services were discontinued or discharged.
F 0584: The facility did not maintain a safe, clean, comfortable, and homelike environment; observed urine odors, sticky floors, missing tiles, stained ceiling tiles, clutter, and unclean resident rooms on multiple units.
F 0610: The facility did not thoroughly investigate an elopement incident involving Resident #37, lacking witness statements and failing to determine how the resident exited the facility.
F 0684: Resident #70 was not provided anti-nausea medication as needed, and emesis, feces, and a full urine bag were observed at the resident's bedside, indicating inadequate care.
F 0760: Resident #5 was administered fast-acting insulin significantly before meal service, risking hypoglycemia due to delayed meal delivery.
F 0761: Medication and treatment carts were found unlocked and unattended; an opened vial of Purified Protein Derivative in the medication refrigerator was not labeled with an opened date.
F 0804: The facility failed to ensure food was palatable and served at safe temperatures; residents complained of burnt, cold, and flavorless food; lasagna was observed burnt on the bottom.
F 0812: The main kitchen had outdated and unlabeled food, unclean stove/oven and shelves, unclean walk-in freezer floor, leaking dish machine, missing wall tiles, unsecured wall covering, and damaged electrical cord on plate warmer.
F 0880: Licensed practical nurse #7 failed to perform hand hygiene after removing gloves during medication administration, risking infection transmission.
F 0925: The facility did not maintain an effective pest control program; fruit flies were observed in the main kitchen and dining areas, ants and house flies were observed on nursing units.
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication carts observed unlocked: 2
Fruit flies observed: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Failed to perform hand hygiene after glove removal during medication administration |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Involved in elopement incident response and investigation |
| Director of Nursing | Director of Nursing | Provided statements on investigation and infection control expectations |
| Director of Maintenance | Director of Maintenance | Provided information on egress door malfunction and pest control |
| Assistant Food Service Director #27 | Assistant Food Service Director | Provided statements on food quality complaints and kitchen cleanliness |
| Cook Supervisor #30 | Cook Supervisor | Provided statements on kitchen cleaning responsibilities and observations |
| Registered Nurse Unit Manager #35 | Registered Nurse Unit Manager | Provided statements on medication cart security and insulin administration timing |
| Physician #13 | Physician | Provided statements on medication orders and expectations for nausea treatment |
| Medical Director | Medical Director | Provided statements on insulin administration timing and hypoglycemia risk |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 17
Date: May 3, 2024
Visit Reason
Multiple standard health and life safety code deficiencies identified and corrected, including food procurement sanitation, infection control, pest control, and fire safety equipment maintenance.
Findings
Multiple standard health and life safety code deficiencies identified and corrected, including food procurement sanitation, infection control, pest control, and fire safety equipment maintenance.
Deficiencies (17)
Food procurement,store/prepare/serve-sanitary
Infection control
Infection prevention & control
Investigate/prevent/correct alleged violation
Maintains effective pest control program
Medicaid/medicare coverage/liability notice
Nutritive value/appear, palatable/prefer temp
Quality of care
Residents are free of significant med errors
Safe/clean/comfortable/homelike environment
Cooking facilities
Electrical equipment - testing and maintenanc
Emergency lighting
Fire alarm system - testing and maintenance
Hazardous areas - enclosure
Maintenance, inspection & testing - doors
Portable fire extinguishers
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jul 15, 2023
Visit Reason
The abbreviated survey was conducted to assess the facility's compliance with providing timely and approved radiology or diagnostic services following a resident's fall.
Findings
The facility failed to provide or obtain a timely ordered x-ray for Resident #1 after a fall, resulting in a delay of three days before the x-ray was completed. Interviews revealed procedural issues and pandemic-related barriers that contributed to the delay.
Deficiencies (1)
F 0776: The facility did not provide timely, approved x-ray services or have an agreement with an approved provider to obtain them. Resident #1 did not receive an ordered x-ray timely after a fall, with the x-ray taking three days to complete.
Report Facts
Residents affected: 1
Days delay: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NP #7 | Nurse Practitioner | Interviewed regarding the resident's condition and x-ray service issues |
| DON #2 | Director of Nursing | Documented progress notes and communicated with x-ray company and family |
| ADON #3 | Assistant Director of Nursing | Interviewed about expectations for x-ray completion timelines |
| RN #4 | Corporate RN | Interviewed regarding x-ray timelines and standards |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jul 15, 2023
Visit Reason
One standard health citation related to radiology/diagnostic services was identified and corrected.
Findings
One standard health citation related to radiology/diagnostic services was identified and corrected.
Deficiencies (1)
Radiology/other diagnostic services
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Feb 28, 2022
Visit Reason
The inspection was a recertification survey conducted from 2/22/22 to 2/28/22 to assess compliance with regulatory requirements for Alpine Rehabilitation and Nursing Center.
Findings
The facility was found deficient in multiple areas including medication self-administration policies, failure to provide Medicare Non-Coverage notices, oxygen administration without physician orders, improper posting of nurse staffing information, medication storage and labeling issues, failure to accommodate resident food preferences, and inadequate kitchen cleanliness.
Deficiencies (7)
F 0554: The facility failed to ensure the right to self-administer medications when clinically appropriate for 1 of 1 resident reviewed. Resident #19 had Diclofenac gel at bedside without documented assessment or physician order for self-administration.
F 0582: The facility failed to provide appropriate liability and appeal notices (NOMNC CMS-10123) to Medicare beneficiaries for 3 of 3 residents reviewed prior to discharge.
F 0695: The facility failed to ensure respiratory care was provided with a medical order for 1 of 1 resident reviewed. Resident #275 was administered oxygen without a physician order.
F 0732: The facility failed to post daily nurse staffing information in a location readily accessible to residents and visitors for 4 of 4 days reviewed.
F 0761: The facility failed to store and label drugs and biologicals properly. Medication carts and storage rooms contained unlabeled, expired, or improperly stored medications and staff drinks were stored in medication carts.
F 0806: The facility failed to ensure food accommodated resident allergies, intolerances, and preferences for 2 of 9 residents reviewed. Resident #58 was not provided food preferences for 3 meals and Resident #55 received a brown, mushy banana instead of fresh.
F 0812: The facility failed to store, prepare, and distribute food in accordance with professional standards. The kitchen exhaust hood, microwave, wall mounted fan, and floors were soiled, dust laden, and unclean.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 1
Days reviewed: 4
Residents affected: 2
Medication carts reviewed: 4
Medication storage rooms reviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Named in medication self-administration and oxygen administration findings |
| LPN #5 | Licensed Practical Nurse | Named in medication self-administration findings |
| Director of Nursing | Director of Nursing | Named in medication self-administration and oxygen administration findings |
| Administrator | Administrator | Named in Medicare Non-Coverage notice deficiency |
| MDS Coordinator | MDS Coordinator | Named in Medicare Non-Coverage notice deficiency |
| RN #12 | Registered Nurse | Named in oxygen administration deficiency |
| Physician #9 | Physician | Named in oxygen administration deficiency |
| Staff scheduler #3 | Staff Scheduler | Named in nurse staffing posting deficiency |
| LPN #8 | Licensed Practical Nurse | Named in medication storage and labeling deficiency |
| Director of Food Service | Director of Food Service | Named in food preference and kitchen cleanliness deficiencies |
| Resident Assistant #10 | Resident Assistant | Named in food preference deficiency |
| Dietary aide #14 | Dietary Aide | Named in food preference deficiency |
| Director of Environmental Services | Director of Environmental Services | Named in kitchen cleanliness deficiency |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 14
Date: Feb 28, 2022
Visit Reason
Multiple standard health and life safety code deficiencies identified and corrected, including food procurement sanitation, drug labeling/storage, Medicaid/Medicare notices, nurse staffing info, resident care, and fire safety equipment.
Findings
Multiple standard health and life safety code deficiencies identified and corrected, including food procurement sanitation, drug labeling/storage, Medicaid/Medicare notices, nurse staffing info, resident care, and fire safety equipment.
Deficiencies (14)
Food procurement,store/prepare/serve-sanitary
Label/store drugs and biologicals
Medicaid/medicare coverage/liability notice
Posted nurse staffing information
Resident allergies, preferences, substitutes
Resident self-admin meds-clinically approp
Respiratory/tracheostomy care and suctioning
Alcohol based hand rub dispenser (abhr)
Doors with self-closing devices
Electrical equipment - testing and maintenanc
Fire alarm system - testing and maintenance
Gas equipment - cylinder and container storag
Hazardous areas - enclosure
Stairways and smokeproof enclosures
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Oct 3, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements including resident dignity, Medicare/Medicaid notice procedures, and infection prevention and control.
Findings
The facility failed to ensure resident dignity related to unclean Geri chairs, did not provide required Medicare/Medicaid coverage notices timely to residents, and did not maintain an adequate infection prevention and control program including improper hand hygiene and glove use during medication administration and unsafe meal service practices.
Deficiencies (3)
F 0550: The facility did not ensure a dignified existence for 1 of 2 residents reviewed, as Resident #18's Geri chair was observed with dried pink debris on multiple days, indicating inadequate cleaning.
F 0582: The facility failed to provide required Medicare/Medicaid coverage notices to 3 residents timely, including failure to provide Skilled Nursing Facility Advance Beneficiary Notice and Notice of Medicare Non-Coverage as required.
F 0880: The facility did not maintain an infection prevention and control program, as staff failed to perform hand hygiene and wear gloves during medication administration and fingerstick procedures, and a dietary aide touched drinking glasses with bare hands during meal service.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 3
Residents observed during meal service: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) #2 | Interviewed regarding unclean Geri chair and dignity concerns | |
| Registered Nurse (RN) #7 | Interviewed regarding training on wheelchair cleaning and infection control | |
| MDS Coordinator #6 | Interviewed regarding Medicare cut letters and notice procedures | |
| Licensed Practical Nurse (LPN) #1 | Observed and interviewed regarding failure to perform hand hygiene and glove use during medication administration | |
| Dietary Aide #8 | Observed and interviewed regarding unsafe handling of drinking glasses during meal service |
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