Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alpine Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A facility failed to provide timely pressure ulcer prevention and wound care for two residents. One resident was admitted with existing pressure ulcers, but pressure relief interventions were not documented in the care plan until later, and the resident continued to have sacral, coccyx, and gluteal fold wounds. Another resident was high risk for pressure ulcers, developed a worsening heel wound that progressed from a blister to a Stage 3 PU, and staff interviews and observations showed inconsistent pressure relief measures and no individualized prevention plan in place at admission.
A meal for residents was prepared without following the planned menu and recipe. Kitchen staff ran short of barbeque chicken thighs after cooking the whole box of frozen chicken without accurately counting servings, and the cheddar broccoli bake was made in one large pan instead of the three pans listed in the recipe. The FSD stated the production sheet should have been followed and that the recipe should have been cooked in three pans, not one.
Two residents did not receive care consistent with professional standards, care plans, and their preferences. One resident with significant medical and cognitive issues went extended periods without a bowel movement, and the facility did not develop a bowel-focused care plan, consistently document bowel interventions, perform and record daily GI/abdominal assessments, or reliably notify the practitioner despite policy requirements. Another resident with dementia, paralysis, seizures, and a history of multiple falls was placed on bed and chair position-change alarms without documented trials of less restrictive fall interventions or a reduction plan, while nursing notes and observations showed frequent alarm activation when the resident attempted to get up to toilet. The resident reported that alarms were distressing, discouraged them from getting up to use the bathroom, and contributed to frequent incontinence, and staff acknowledged alarms were initiated without other interventions first and were not treated as restraints or tied to a documented medical symptom.
Insulin Pen Not Primed Before Administration: An LPN administered aspart insulin to a resident with diabetes using a pen injector without priming the pen first. The resident had moderately impaired cognition and received daily insulin injections. The LPN stated priming was not needed, while the RN Unit Manager stated the pen should be primed with a waste dose before use to ensure the correct dose is delivered.
The facility failed to ensure that drugs and biologicals were labeled and stored properly, with medication and treatment carts found unlocked and unattended, and an open vial of Purified Protein Derivative not labeled with an opened date.
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Observations revealed outdated and undated food items, unclean kitchen equipment, and structural issues. Staff interviews indicated a lack of awareness and adherence to cleaning protocols, contributing to the deficiency.
The facility failed to maintain an effective pest control program, resulting in the presence of ants, house flies, and fruit flies in various areas. Despite having a policy for monthly inspections and emergency responses, the facility's records only documented treatments for ants, and multiple instances of pest presence were observed during the survey.
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents in both the North and South Units. Observations revealed strong urine odors, sticky floors, missing paint, cluttered refuse, and unclean conditions in multiple resident rooms and common areas. Staff interviews confirmed these issues and highlighted lapses in daily cleaning and maintenance protocols.
The facility failed to provide required Medicare notices to two residents, resulting in a lack of awareness about the termination of services and appeal rights. One resident remained in the facility without receiving a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage, and another was discharged home without a Notice of Medicare Non-Coverage.
A resident with diabetes was administered fast-acting insulin well before meals, leading to a risk of hypoglycemia. Staff interviews and observations revealed that insulin was given without ensuring timely meal delivery, contrary to the facility's policy. This discrepancy resulted in the resident consuming snacks to manage blood sugar levels, highlighting a significant lapse in medication management.
An LPN failed to perform hand hygiene after removing gloves and before administering medications to another resident, despite having completed multiple infection control training sessions. This lapse in protocol was observed during a recertification survey and acknowledged by both the LPN and the Director of Nursing.
A resident with dementia eloped from the facility through an egress door that did not alarm. The investigation was incomplete, lacking witness statements and a clear explanation of the door malfunction. Staff interviews revealed the door was unlocked and unalarmed, but the facility could not determine how the resident exited.
A resident with end-stage renal disease and other conditions did not receive necessary anti-nausea medication and was found in an undignified state with a full urine bag, feces-soiled brief, and vomit at the bedside. Staff failed to follow proper procedures for urinary catheter care, reporting emesis, and administering medication.
The facility failed to ensure that residents received palatable, flavorful, and appetizing food. Observations and interviews revealed that the lasagna served was burnt, and multiple residents complained about the food being overcooked, cold, and lacking flavor. Staff confirmed these complaints, indicating a failure to implement the facility's taste testing policy effectively.
Failure to Provide Timely Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer care and pressure relief measures for two residents who were at risk for, or already had, pressure ulcers. The report cites 10 NYCRR 415.12(c)(1) and describes that the facility did not ensure necessary treatment and services were provided consistent with professional standards of practice to promote wound healing, prevent infection, and prevent new ulcers from developing. Resident #64 was admitted with existing Stage 2 and Stage 3 pressure ulcers and was dependent for all activities of daily living, including bed mobility. The admission MDS documented that the resident was at risk for pressure ulcers and had pressure reducing devices for bed and chair, was on a turning and repositioning schedule, and received ointments and medications. However, the record showed no documented evidence that the comprehensive care plan included pressure reducing devices or pressure relief interventions until after the resident returned from a hospital stay. On readmission, the resident had moisture associated skin damage on the left buttock and a Stage 3 pressure ulcer to the sacrum. Later treatment observation showed a coccyx pressure ulcer, blister-type areas on the sacral area, and an open wound in the gluteal fold with yellowish and white tissue. Resident #24 had diagnoses including right hip fracture, intellectual disabilities, and seizures, and the MDS identified the resident as at risk for pressure ulcers with an unhealed Stage 3 pressure ulcer and use of a pressure reducing device for the chair. The care plan initially addressed only monitoring and documenting skin changes. The resident developed a large deflated blister on the right heel that progressed to a ruptured blister, then a Stage 2 pressure ulcer, and later a Stage 3 pressure ulcer. Survey observations showed the resident sitting in a wheelchair with black surgical boots or ortho shoes and both feet on the floor, and there was no heel suspension boot in the room during one observation. Staff interviews indicated the resident had not had individualized pressure ulcer prevention interventions in place on admission, that heel suspension boots were initiated later, and that the resident’s family had brought in surgical boots from home. The DON stated there were not any specific individualized care plans initiated for the resident to prevent pressure ulcers upon admission and that the interventions on the care plan were not 100% appropriate or effective, as the resident developed a pressure ulcer.
Menu and Recipe Not Followed During Meal Preparation
Penalty
Summary
The facility failed to ensure resident menus were followed during a lunch meal preparation for 75 residents. The week one Fall Winter 2024-2025 menu listed barbeque chicken, garden rice, cheddar broccoli bake, and rosy pears, with alternatives of fish on a bun, mashed potatoes, and spinach. The menu tally for that meal documented 58 barbeque chickens total, including a buffer, but during preparation the kitchen later determined it was short nine servings of chicken thighs. Staff stated they had pulled the chicken from the freezer on the prior Sunday, cooked the whole box, and were not sure how many chicken thighs were in a box. The Food Service Director stated the production sheet was supposed to be followed and the chicken thighs counted, but the meal still ran short. The facility also did not follow the cheddar baked broccoli recipe as written. The undated recipe called for three quarts of cheddar baked broccoli to be poured into each of three greased 12 by 20 by 2 inch pans, but during observation the broccoli was placed in one 12 by 20 by 6 inch hotel pan and repeatedly returned to the oven because it was not up to temperature or was still hard. The Food Service Director and staff then moved portions into smaller pans, placed them on the stove with hot water from a hose, and continued warming them. One portion measured 165 degrees Fahrenheit and was described as good and tender, while the remaining broccoli was still being warmed as plating began. The Food Service Director stated the recipe should have been cooked in three pans, not one, and that the recipe had not turned out right.
Failure to Manage Bowel Function and Use Position-Change Alarms Consistent With Standards and Resident Choice
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards, the comprehensive person-centered care plan, and resident choices for two residents. For one resident with schizophrenia, morbid obesity, and a history of intestinal bypass, the facility did not develop a comprehensive care plan that addressed bowel function despite the resident being bowel incontinent and requiring assistance with activities of daily living. Bowel documentation showed the resident went four days without a bowel movement, then later went ten consecutive days without a bowel movement. During these periods, there was no documented evidence that nursing staff consistently implemented bowel interventions, performed and recorded daily gastrointestinal or abdominal assessments, or consistently notified the practitioner as required by facility policy, which identified four or more days without a bowel movement as a red flag requiring immediate assessment and practitioner notification. Progress notes and medication records showed that the resident received laxatives and suppositories at certain points, but there were gaps in documentation and an order for a rectal enema that was not documented as administered. A nurse practitioner documented constipation and later an abdominal exam with active bowel sounds, but there was no documented gastrointestinal assessment when constipation was first noted, and no evidence that the practitioner was informed of the ongoing absence of bowel movements over multiple days. A physician later documented that the resident was doing well without gastrointestinal complaints and noted a normal abdominal exam, but there was no documentation that the physician was made aware that the resident had not had a bowel movement for several days. Daily 24-hour report sheets and nursing progress notes did not reflect ongoing monitoring of bowel status, abdominal assessments, or repeated physician notifications during the extended period without bowel movements. The second resident had dementia, paralysis and weakness following a brain bleed, seizures, and a history of multiple falls with and without injury. The comprehensive care plan included bed and chair alarms, a low bed, and floor mats as fall interventions, as well as assistance with toileting and mobility and a plan to check and change and toilet the resident every two to three hours. However, the care plan did not document any less restrictive fall prevention interventions trialed before initiating position-change alarms, nor did it include a process for systematic and gradual reduction of alarm use. Accident and incident reports documented multiple falls over several months, including falls from bed, wheelchair, in the bathroom, and a fall associated with urinating on the floor, yet there was no documented attempt to determine the root cause of the resident’s repeated attempts to rise or non-compliance with alarms, and no documentation of alternative interventions being tried. Nursing notes repeatedly described the resident as non-compliant with alarms, frequently attempting to self-transfer, getting up to walk to the bathroom, and being incontinent while ambulating, but did not document assessment of why the resident was doing so or any modification of the toileting or fall-prevention approach. Observations showed that the resident’s bed and chair alarms sounded whenever they attempted to stand or even reposition, prompting staff to rush in and direct the resident to sit back down. In interviews, the resident reported disliking the alarms, stating that they were not asked how they felt about them, that the alarms startled them, made them feel as though they were doing something wrong, and discouraged them from getting up to use the bathroom, leading to frequent bladder accidents and feelings of lost liberty. Staff interviews confirmed that alarms were initiated for this resident without trying other interventions first, that alarms were not treated as restraints and did not require orders or documented medical symptoms, and that the resident was not on a set toileting schedule despite frequently asking to use the bathroom and attempting to get up to urinate. Facility leadership and nursing staff stated that bowel movements were supposed to be monitored daily, with provider notification and abdominal assessments after two or more days without a bowel movement, and that residents should be toileted per the care plan and alarms used with consideration of resident feelings. However, for the first resident, there was no documentation of daily abdominal assessments, consistent bowel interventions, or ongoing practitioner notification during prolonged constipation, and the bowel management care planning was incomplete. For the second resident, alarms were used as a primary intervention without documented trials of less restrictive measures, without a documented reduction plan, and without documented exploration of the resident’s toileting needs and preferences, despite the resident’s expressed distress and frequent attempts to get up to use the bathroom. These actions and omissions resulted in care that did not align with facility policies on bowel management, toileting, fall risk management, and restraint use, and did not fully honor the residents’ choices and person-centered care plans.
Insulin Pen Not Primed Before Administration
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when Resident #2’s insulin pen was administered without being primed first. Resident #2 had diagnoses including diabetes, had moderately impaired cognition on the 12/16/2025 MDS assessment, and received daily insulin injections. The resident’s care plan documented diabetes and included diabetes medications as ordered by the physician. The 01/19/2026 physician order directed aspart insulin five units daily with meals via pen injector. During observation and interview on 04/01/2026 at 12:50 PM, an LPN attached the needle to the aspart insulin pen, dialed it to five units, and administered it to the resident without priming the pen first. The LPN stated priming was not needed because pushing the button during administration was priming. The RN Unit Manager stated that after attaching the needle, the pen should be primed with a waste dose of one or two units and that failure to do so could leave air in the needle so the correct dose would not be given.
Medication and Treatment Cart Security and Labeling Deficiency
Penalty
Summary
The facility did not ensure that drugs and biologicals were labeled and stored in accordance with currently accepted professional principles. Specifically, the North Unit medication and treatment carts were found unlocked and unattended on multiple occasions. Additionally, an open vial of Purified Protein Derivative in the North Unit refrigerator was not labeled with an opened date. These observations were made during the recertification survey conducted from 4/29/2024 to 5/3/2024. The facility policy required medications and biologicals to be stored safely, securely, and properly, following manufacturer's recommendations, and to be dated when opened if they had shortened expiration dates. During interviews, staff members acknowledged the importance of keeping medication and treatment carts locked to prevent unauthorized access and potential harm to residents. Licensed practical nurse #7 admitted to leaving the medication cart unlocked while passing meal trays and not knowing how long it had been unlocked. The Director of Nursing and the registered nurse Unit Manager both confirmed that medication and treatment carts should always be locked when not in use. The Director of Nursing also stated that Purified Protein Derivative should be dated when opened and discarded after 30 days.
Deficiency in Food Service Safety Standards
Penalty
Summary
The facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Observations revealed outdated and undated food items, such as jelly with an opened label date of 4/16 and a container of ham-based paste without an open date. The stove/oven/flattop combo unit and the shelf above it were found to be unclean, with food debris and stickiness present. Additionally, the walk-in freezer floor was not clean, and the dish machine was leaking water, with a plastic bucket placed underneath to collect the water. The kitchen also had structural issues, including missing tiles at the bottom of the handwash sink, an unsecured metal wall cover, and a plate warmer cord in disrepair wrapped with electrical tape. Interviews with staff revealed a lack of awareness and adherence to cleaning protocols. The Assistant Food Service Director was unaware of the kitchen's environmental issues and stated that it was their responsibility to maintain a clean kitchen environment. Cook Supervisor #30 admitted that the stove/oven/flattop combo unit and the shelf above it should have been cleaned daily but had not been cleaned for a couple of days. Cook #31 confirmed that they had never cleaned the walk-in freezer floor since being hired and had not completed the task of de-icing the freezer as required. The Assistant Food Service Director also assumed that staff would keep the floor clean as part of the de-icing task but was not aware that the task had not been completed. The facility's cleaning policies and schedules were not followed consistently, leading to the observed deficiencies. The Cleaning Schedule for Saturday documented tasks that were not completed, and the Dietary Department Daily Cleaning & Closing Checklist showed that certain areas were signed off as cleaned when they were not. The Director of Environmental Services stated that ceilings would be cleaned as needed, but the ceiling in the dish machine area was found to be stained and unclean. The lack of proper cleaning and maintenance in the kitchen environment contributed to the overall deficiency in food service safety standards.
Ineffective Pest Control Program
Penalty
Summary
The facility did not maintain an effective pest control program, resulting in the presence of ants, house flies, and fruit flies in various areas. Specifically, ants were observed on the South Unit, while fruit flies were found on the North Unit and in the main kitchen. The facility's pest control policy, effective since October 2017, required monthly inspections and emergency responses by a licensed pest control company. However, pest control vendor records from March and April 2024 only documented targeted treatments for ants, with no mention of flies or fruit flies. Additionally, the facility's pest sighting log did not record any sightings of flies or fruit flies from November 2023 to April 2024, despite multiple observations of these pests during the survey period. During the survey, numerous instances of pest presence were documented. On April 29, 2024, 25 fruit flies were observed in the main kitchen dish machine area, and individual fruit flies were seen in various hallways and the main dining room. Ants were observed on a puzzle table between resident rooms on April 30 and May 1, 2024. House flies were found on a windowsill in a resident's room and flying around a day room where a resident was eating. Interviews with the Director of Maintenance and the Director of Environmental Services revealed that staff were trained to report pest sightings to maintenance, who would then contact the pest control vendor. However, the Director of Environmental Services acknowledged that it was unacceptable for flies to land on residents' food trays and could not confirm if the fruit flies in the main kitchen were present before the survey began.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for two resident units. Specifically, the South Unit hallways and common areas smelled of urine and had sticky floors. There was a stained ceiling tile on the South Unit, and several resident rooms had sticky floors, strips of missing paint, and cluttered refuse. The South Unit shower room had tiles missing around the drain, and multiple resident rooms smelled of urine. Observations were made over several days, indicating ongoing issues with cleanliness and maintenance in these areas. On the North Unit, similar issues were observed. Resident rooms had unclean, sticky floors, and were cluttered with books, food, soda, water bottles, paper, cups, tubing, and personal items. Some rooms had a strong urine odor, and crumbs and dirty linen were found on the floors. Residents expressed dissatisfaction with the cleanliness of their rooms, stating that debris had been present for several days. These conditions were confirmed by staff interviews, where it was acknowledged that the environment was not homelike and could lead to odors, bugs, and infection control issues. Interviews with the Director of Maintenance and the Director of Environmental Services revealed that the facility had policies in place for daily cleaning and maintenance, but these were not being effectively implemented. The Director of Maintenance expected resident rooms to be swept and cleaned daily, and the Director of Environmental Services stated that damaged walls and other environmental concerns should be repaired as soon as they were observed. Despite these expectations, the facility failed to maintain a clean and homelike environment for its residents, as evidenced by the numerous observations of unclean and cluttered conditions.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to provide the appropriate liability and appeal notices to Medicare beneficiaries for two residents. Resident #71 remained in the facility after the discontinuation of Medicare Part A services without receiving a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (CMS-10055) as required. The resident's representative was informed via phone about the termination of services, but the necessary documentation was not provided, leaving the resident unaware of their appeal rights and potential liability for services not covered by Medicare Part A. Resident #233 was discharged home without receiving a Notice of Medicare Non-Coverage (CMS-10123) for Medicare Part A. The resident's Medicare Part A skilled services ended on the day of discharge, but no notice was generated or provided to inform the resident of the termination of services and their appeal rights. The Financial Coordinator was unaware of the requirement to issue these notices, leading to a failure in communication and documentation. Interviews with the Financial Coordinator and the Administrator revealed a lack of awareness and understanding of the requirements for issuing these notices. The responsibility for issuing the notices had shifted from the Minimum Data Set person to the finance department, but the necessary training and knowledge transfer did not occur. This oversight resulted in residents not being properly informed about the termination of their Medicare services and their rights to appeal, as required by CMS regulations.
Significant Medication Error Due to Improper Insulin Administration Timing
Penalty
Summary
The facility failed to ensure that Resident #5 was free from significant medication errors, specifically related to the administration of Humalog insulin. The resident, who had diabetes and was cognitively intact, was administered fast-acting insulin before meals, but meals were often served late. This discrepancy between insulin administration and meal times placed the resident at risk for hypoglycemia. On multiple occasions, the resident received their insulin well before their meal was served, leading them to consume snacks to manage their blood sugar levels. For instance, on 4/30/2024, the resident received insulin at 7:39 AM, but breakfast was served after 9:00 AM. Similarly, on 5/1/2024, the resident received insulin at 7:42 AM, but breakfast was served at 8:40 AM, causing the resident to eat chips to prevent hypoglycemia. Interviews with staff, including LPNs, RNs, and the Director of Nursing, revealed a lack of adherence to the facility's policy on blood glucose management. The policy required that fast-acting insulin be administered no earlier than 15 minutes before a meal to prevent hypoglycemia. However, staff admitted to administering insulin without ensuring that the resident had their meal tray in front of them. The Director of Nursing and the Medical Director both confirmed that administering fast-acting insulin without food could lead to significant medication errors and hypoglycemia. The facility's failure to coordinate insulin administration with meal times was evident in the observations and interviews. The resident's blood glucose levels were monitored, but the timing of insulin administration did not align with meal delivery, leading to potential health risks. The staff's inconsistent practices and the delayed meal service contributed to the deficiency, highlighting a significant lapse in the facility's medication management and resident care protocols.
Infection Control Deficiency Due to LPN's Failure to Perform Hand Hygiene
Penalty
Summary
The facility did not maintain an infection prevention and control program as evidenced by the actions of one licensed practical nurse (LPN) during medication administration. Specifically, the LPN did not perform hand hygiene after removing gloves and before administering medications to another resident. This was observed during a recertification survey, where the LPN was seen applying gloves, cleaning a glucometer, removing the gloves, and then putting on another pair of gloves without sanitizing their hands in between. The LPN admitted to not washing or sanitizing their hands between resident contact and acknowledged the importance of hand hygiene in preventing the spread of infections. The LPN had completed multiple training sessions on infection control, including hand hygiene, as documented in their education records. Despite this training, the LPN failed to follow proper hand hygiene protocols during the observed medication administration. The Director of Nursing confirmed that all staff were trained annually on infection control and emphasized the expectation for hands to be washed or sanitized after resident contact and glove removal to prevent the spread of infections. The failure to perform hand hygiene as required could lead to the transmission of communicable diseases and infections among residents, staff, visitors, and families.
Incomplete Investigation of Resident Elopement
Penalty
Summary
The facility did not ensure all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for a resident who eloped from the facility. The resident, diagnosed with Pick's disease and pseudobulbar affect, exited through an egress door without being detected. The incident was reported by a family member, and the resident was brought back inside without injury. However, the investigation into the incident was incomplete and did not determine how the resident was able to exit the facility. The investigation lacked documented witness statements from the family member who reported the resident outside and the visitor who witnessed the resident exiting. The Director of Maintenance checked the egress doors and found no issues, but later admitted there was a malfunction on the timer of the door. The malfunction was not clearly explained, and no vendor was called to inspect the door. The facility's Director of Nursing and Administrator were unable to determine how the door malfunctioned or how long it had been unlocked and unalarmed. Interviews with staff revealed that the door did not alarm when the resident exited, and the keypad light was green, indicating it was unlocked. The staff who retrieved the resident also noted the door was unlocked and did not alarm. The facility's investigation did not include a review of camera footage or a formal statement from the family visitors who witnessed the incident. The Director of Nursing and Administrator were not fully informed of the details of the door's malfunction or the investigation's findings.
Failure to Provide Appropriate Treatment and Maintain Dignity
Penalty
Summary
The facility failed to ensure that Resident #70 received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's personal preferences. Specifically, Resident #70, who had diagnoses including end-stage renal disease, bladder injury, and heart failure, was not provided with anti-nausea medications when needed. Despite having a physician's order for ondansetron to manage nausea, the medication was not administered as required, and there was no documented evidence that the medical provider was notified of the resident's emesis to re-evaluate the need for a new order for the medication. Additionally, the resident's complaints of nausea were not adequately addressed, and the medication administration record did not document the administration of ondansetron on the specified dates when the resident complained of nausea. Observations revealed that Resident #70 was found in an undignified state, with a full urine collection bag, a feces-soiled brief, and a basin of vomit at the bedside. The resident was observed nude, with their bare backside visible from the doorway and to their roommates. The urine collection bag was not emptied as required, and the resident's room was not maintained in a clean and dignified manner. Certified Nurse Aide #16 and Registered Nurse Unit Manager #15 confirmed that the urine bags should be emptied every shift and should not be left on the floor. They also acknowledged that the presence of urine, feces, and emesis at the bedside was not dignified and posed an infection control issue. Interviews with staff, including the Director of Nursing and the resident's nurse, revealed that the staff failed to follow proper procedures for urinary catheter care, reporting emesis, and administering anti-nausea medication. The resident's nurse admitted to overlooking the order for the anti-nausea medication while attempting to manage the resident's pain. The physician expected the nursing staff to complete an assessment and administer as-needed medications as ordered. The failure to provide timely and appropriate care resulted in the resident experiencing unnecessary discomfort and a lack of dignity in their care environment.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility did not ensure that each resident received food and drink that was palatable, flavorful, and appetizing. During the recertification and abbreviated surveys, it was observed that the lasagna served at a lunch meal was burnt, and multiple residents complained about the food quality. Specifically, seven residents at a Resident Council meeting reported that the food was often overcooked, lacked flavor, and was not served at palatable temperatures. One resident mentioned receiving cold toast for breakfast, and another resident showed a burnt corner of their lasagna. Additionally, a food tray tested for another resident revealed that the lasagna was burnt and blackened at the bottom, despite being at an acceptable temperature. Interviews with various staff members, including certified nurse aides and licensed practical nurses, confirmed that residents frequently complained about the food being burnt, cold, and lacking flavor. The Assistant Food Service Director acknowledged that residents had complained about overcooked food in the past and emphasized the importance of serving appetizing and palatable food. The facility's policy on taste testing documented that all food should be taste tested prior to meal service, and any food that did not pass the taste test should not be served until the problem was corrected. However, the observations and interviews indicated that this policy was not effectively implemented, leading to the deficiency.
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Illustrative
What surveyors actually found near you
We read the 117 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Little Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Foltsbrook Center For Nursing And Rehabilitation | 6.9 mi | ★★★★★ | 0 | 0 |
| Valley Health Services Inc | 7.6 mi | ★★★★★ | 26 | 0 |
| St Johnsville Rehabilitation And Nursing Center | 9.2 mi | ★★★★★ | 26 | 0 |
| The Grand Rehabilitation And Nursing At Mohawk | 10.1 mi | ★★★★★ | 3 | 1 |
| Masonic Care Community Of New York | 17 mi | ★★★★★ | 35 | 1 |
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