Alpine Meadow Rehabilitation and Nursing

In the surveyor’s words

From the most serious findings on record at Alpine Meadow Rehabilitation and Nursing, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 24, 2023

  Based on observation, interview and record review, it was determined for 4 out of 13 sampled residents, that the facility failed to ensure that the residents environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident received and partially consumed a meal that had not been mechanically altered per the physician orders which resulted in the resident choking on the food and requiring emergency medical attention. Additionally, 3 other residents received and/or consumed meals that were not mechanically altered per the physician orders. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. […]

• Immediate jeopardy, isolatedF805Aug 24, 2023

  Based on observation, interview and record review, it was determined for 4 out of 13 sampled residents, that the facility failed to ensure that the residents received food prepared in a form designed to meet their individual needs. Specifically, a resident received and partially consumed a meal that had not been mechanically altered per the physician orders which resulted in the resident choking on the food and requiring emergency medical attention. Additionally, 3 other residents received and/or consumed meals that were not mechanically altered per the physician orders. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. Resident identifier: 1, 5, 6, and 14. […]

• No harm, potential for more than minimal, widespreadF880Dec 21, 2023

  Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including Coronavirus Disease 2019 (COVID-19). Specifically, during a COVID-19 outbreak the facility staff did not dispose of their used Personal Protective Equipment (PPE) correctly, staff did not wear eye protection when entering COVID positive resident rooms, meal trays were not bagged and identified when taken from COVID positive resident rooms and a symptomatic resident was not tested promptly for COVID-19 after staff were made aware. Resident identifier: 4 & 35. Findings included: 1. […]

• No harm, potential for more than minimal, widespreadF801Aug 24, 2023

  Based on interview and record review, it was determined that the facility did not employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. Specifically, the facility did not employ a qualified dietary manager that possesses one or more of the following credentials: Certified Dietary Manager, Certified Food Service Manager, a Food Service Management Certificate, 2 or more years of experience in a nursing facility setting as a food service director and has completed a course of study in food safety and management, or an associates degree or higher with coursework in food service, hospitality, or restaurant management. […]

• No harm, potential for more than minimal, patternF756Apr 22, 2026

  Based on interview and record review, the facility did not ensure that the irregularities reported by the pharmacist to the attending physician and Medical Director (MD) were acted upon. In addition, the facility did not ensure the attending physician documented in the resident's medical record that the identified irregularity had been reviewed and what, if any, action had been taken to address it. Specifically, for 5 out of 20 sampled residents, pharmacy recommendations were not acted upon by the MD and the MD did not document the identified irregularity and what action was taken in the resident's medical record. Resident identifiers: 10, 18, 19, 24, and 34.Findings included:1. […]