Deficiency Records for Alpine Skilled Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Alpine Skilled Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-20 | 2023-04-30 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-03-20 | 2023-04-30 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-03-20 | 2023-04-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-20 | 2023-04-30 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-03-20 | 2023-04-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-20 | 2023-04-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-20 | 2023-04-30 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-03-20 | 2023-04-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-20 | 2023-04-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-20 | 2023-04-30 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-03-20 | 2023-04-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-20 | 2023-04-30 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-03-20 | 2023-04-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-20 | 2023-04-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-20 | 2023-04-30 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-03-21 | 2023-04-30 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-03-21 | 2023-04-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-21 | 2023-04-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-21 | 2023-04-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-21 | 2023-04-30 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-03-21 | 2023-04-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-21 | 2023-04-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-21 | 2023-04-30 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-03-21 | 2023-04-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-21 | 2023-04-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-21 | 2023-04-30 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-18 | 2023-02-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-18 | 2023-02-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-30 | 2022-10-17 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-08-30 | 2022-10-17 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-16 | 2022-07-28 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-05-16 | 2022-07-28 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-16 | 2022-07-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-16 | 2022-07-28 | N |
| Respond appropriately to all alleged violations. | Health | 2022-05-16 | 2022-07-28 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-05-16 | 2022-07-28 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-05-16 | 2022-07-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-16 | 2022-07-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-16 | 2022-07-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-16 | 2022-07-28 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-05-16 | 2022-07-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-16 | 2022-07-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-05-16 | 2022-07-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-16 | 2022-07-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-05-16 | 2022-07-28 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-05-16 | 2022-07-28 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-05-16 | 2022-07-28 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-05-16 | 2022-07-28 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-05-16 | 2022-07-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-16 | 2022-07-28 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-05-16 | 2022-07-28 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-05-16 | 2022-07-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-16 | 2022-07-28 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-05-16 | 2022-07-28 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-05-16 | 2022-07-28 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-16 | 2022-07-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-16 | 2022-07-27 | N |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2022-05-16 | 2022-07-26 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-05-18 | 2022-07-26 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-05-18 | 2022-07-26 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-05-18 | 2022-07-26 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-05-18 | 2022-07-26 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-05-18 | 2022-07-26 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-05-18 | 2022-07-26 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-05-18 | 2022-07-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-05-18 | 2022-07-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-18 | 2022-07-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-05-18 | 2022-07-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-18 | 2022-07-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-05-18 | 2022-07-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-05-18 | 2022-07-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-16 | 2022-07-22 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-01-20 | 2022-03-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-20 | 2022-03-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-20 | 2022-01-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-07-15 | 2021-08-30 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-07-21 | 2021-08-30 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-07-21 | 2021-08-30 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-07-21 | 2021-08-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-07-21 | 2021-08-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-07-21 | 2021-08-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-21 | 2021-08-30 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-07-21 | 2021-08-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-21 | 2021-08-30 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-07-21 | 2021-08-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-21 | 2021-08-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-07-21 | 2021-08-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-07-21 | 2021-08-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-21 | 2021-08-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-07-21 | 2021-08-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-07-21 | 2021-08-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-21 | 2021-08-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-07-21 | 2021-08-30 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-07-21 | 2021-08-20 | N |
| Respond appropriately to all alleged violations. | Health | 2021-07-15 | 2021-08-13 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-07-15 | 2021-08-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-15 | 2021-08-13 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-07-15 | 2021-08-13 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-07-15 | 2021-08-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-15 | 2021-08-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-15 | 2021-08-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-15 | 2021-08-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-07-15 | 2021-08-13 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2021-07-15 | 2021-08-13 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-07-15 | 2021-08-13 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-07-15 | 2021-08-13 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-07-15 | 2021-08-13 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-07-15 | 2021-08-13 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-07-15 | 2021-08-13 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2021-07-15 | 2021-08-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-15 | 2021-08-13 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-07-15 | 2021-08-13 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-07-15 | 2021-08-13 | N |
| Provide or obtain dental services for each resident. | Health | 2021-07-15 | 2021-08-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-15 | 2021-08-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-29 | 2021-05-21 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-04-29 | 2021-05-21 | Y |
