Pennsylvania Department of Health
ALPINE VALLEY POST ACUTE AND HEALTHCARE CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ALPINE VALLEY POST ACUTE AND HEALTHCARE CENTER
Inspection Results For:

There are 98 surveys for this facility. Please select a date to view the survey results.

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ALPINE VALLEY POST ACUTE AND HEALTHCARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a State Licensure survey and an Abbreviated survey in response to a complaint completed on October 23, 2025, it was determined that Alpine Valley Post Acute and Healthcare Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2)(i)-(iii) REQUIREMENT Discharge Process:

§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:

(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1 ) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).

Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident and the resident's representative of the bed hold and transfer notices, including the reasons for the move, and Ombudsman information, in writing at the time of a facility-initiated transfer from the facility for two of two sampled residents who were transferred to the hospital. (Residents 28 and 69)

Findings include:

Clinical record review revealed that Resident 28 was transferred and admitted to the hospital on September 9, 2025, after a change in condition. There was no documentation to support that the resident's representative was provided written information regarding the bed hold policy or the transfer to the hospital at the time of the facility-initiated transfer.

Clinical record review revealed that Resident 69 was transferred and admitted to the hospital on October 14, 2025, after a change in condition. There was no documentation to support that the resident's representative was provided written information regarding the bed hold policy or the transfer to the hospital at the time of the facility-initiated transfer.

In interviews on October 23, 2025, at 11:42 p.m. and 11:52 p.m., the Administrator confirmed that the written notifications of transfer were not sent to the identified residents and resident representatives.

28 Pa Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.18(b)(2) Management.

Plan of Correction - To be completed: 11/18/2025

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.

1. For residents 28 and 69, were provided with a copy of written notice of transfer and bed hold.
2. An audit will be completed of facility-initiated transfers to the hospital for the last 30 days to ensure written transfer and bed hold notices were provided in writing to the identified responsible party. Variances were addressed at the time of the audit and placed on facility audit tool.
3. Facility Nursing Administration, Social Services, Business office, Registered Nurse Supervisors will be educated by NHA or Designee, related to policy and procedure for Transfer and Bed Hold Notice Letter need to be mailed to the responsible party unless at bedside and copy provided with appropriate documentation.
4. A Quality Assurance and Performance Improvement plan will be developed. NHA or designee will complete random audits of 3 hospital transfers weekly for 4 weeks and then monthly for 2 months to ensure the written transfer and bed hold notice letter was mailed to the responsible party. Audit findings will be reported to the monthly QAA for review and recommendations.

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Plan of Correction - To be completed: 11/18/2025

1. Resident 13, 21, 29, 38, 48, 94 were assessed upon notification and had no noted side effects on November 4th, 2025.
2. An initial audit was completed of residents with as needed cardiac medications to ensure parameters were followed in the last 30 days. An audit will be completed of current residents bowel movement records for the last 14 days to determine if bowel regimen orders were followed as needed. Variances were addressed at the time of the audit and placed on facility audit tool.
3. Facility Licensed Nursing staff will be educated by DON or designee, on the policy and procedure for following physician orders.
4. A Quality Assurance and Performance Improvement plan will be developed. DNS or designee will complete random audits of 10 resident's weekly who have as needed hypertension medications or signs of constipation for 4 weeks and then monthly for 2 months to ensure the physician orders are followed. Audit findings will be reported to the monthly QAA for review and recommendations.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(f). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Observations:

Based on a review of facility documentation and clinical record review, it was determined that the facility failed to ensure that each resident was provided medication as prescribed by the physician for one of 25 sampled residents. (Resident 11)

Findings include:

Review of the facility "Pharmacy Services Provider Agreement", dated November 22, 2024, revealed that the pharmacy was to deliver prescriptions and supplies to the facility twice per day. Review of the pharmacy delivery information revealed the pharmacy made one scheduled delivery on Saturdays and Sundays. In an interview on October 22, 2025, at 10:10 a.m., the Administrator confirmed that all orders placed in the facility's electronic medical record system were transmitted to the pharmacy electronically.

Clinical record review revealed that Resident 11 had diagnoses that included multiple sclerosis, a history of a stroke with continued weakness to one side of the body, and diabetes. Review of a nursing progress note dated September 13, 2025, at 10:37 p.m., indicated a new order was placed for an antibiotic ointment (erythromycin ointment) to treat an upper eyelid stye. A physician's order entered September 13, 2025, at 10::37 p.m., directed staff to administer the antibiotic ointment medication to treat an eyelid stye two times a day for seven days starting September 14, 2025, at 8:00 p.m. Review of the Medication Administration Record for September 2025, revealed no evidence that the resident received the medication on September 14, 2025. Review of a medication administration note from that evening at 9:45 p.m., indicated that the medication had not been delivered. Review of a nurse practitioner's note dated September 15, 2025, at 1:27 p.m., indicated the ointment was ordered but not yet delivered by the pharmacy.

28 Pa. Code 201.18(b)(1) Management.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Plan of Correction - To be completed: 11/18/2025

1. Resident 11 received eye treatment and provider notified of change in start date.
2. An initial audit was completed of current residents with new medication related physician orders in last 14 days to ensure medications were received and if any doses missed, the provider was notified. Variances were addressed at the time of the audit and placed on facility audit tool.
3. Facility licenses nursing staff will be educated by DON or designee, on policy and procedure for when medications is not available.
4. A Quality Assurance and Performance Improvement plan will be developed. DNS or designee will complete random audits weekly of 10 new medication orders of current residents for 4 weeks and then monthly for 2 months to ensure medications are available for administration. Audit findings will be reported to the monthly QAA for review and recommendations.

483.60(d)(4)(5) REQUIREMENT Resident Allergies, Preferences, Substitutes:

§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences;

§483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice;

Observations:
Based on clinical record review, observation, resident interview, and staff interview, it was determined that the facility failed to accommodate each resident's food preferences for one of 25 sampled residents. (Resident 19)

Findings include:

Review of facility menus for the lunch meal on October 22, 2025, revealed that the meal included honey glazed turkey breast, red bliss potatoes, mixed vegetables, pineapple tidbits, milk, and coffee or hot tea, with an alternate menu item of bratwurst.

Clinical record review revealed that Resident 19 had diagnoses that included hypertension, diabetes, and malnutrition. Review of the Minimum Data Set assessment dated August 17, 2025, revealed that the resident was alert and oriented and able to make her needs known. Review of the resident's meal ticket revealed that she requested honey glazed turkey breast, bratwurst, pineapple tidbits, and coffee for the meal. On October 22, 2025, at 12:30 p.m., Resident 9 was observed with her lunch tray. The tray contained a peanut butter and jelly sandwich, a bratwurst, peas and carrots, fried potatoes, and juice. There was no turkey, coffee, or pineapple tidbits on the tray. In an interview at that time, Resident 19 stated that she often does not get what she orders and was looking forward to having the pineapple and coffee.

In an interview on October 23, 2025, at 10:15 a.m., the Administrator stated that Resident 19's preferences were not followed for the above lunch meal.

201.14(a) Responsibility of licensee.

28 Pa. Code 201.18(b)(1) Management.

Plan of Correction - To be completed: 11/18/2025

1. Resident 19 had a grievance completed for food preferences not followed.
2. An initial audit was completed of past 3 months of grievance logs to review other residents' concerns related to food preferences. Variances were addressed at the time of the audit and placed on facility audit tool.
3. Facility dietary and nursing staff will be educated by DON or designee, that resident food preferences are to be followed as per documentation.
4. A Quality Assurance and Performance Improvement plan will be developed. NHA or designee will complete random audits of 10 resident meals weekly for 4 weeks and then monthly for 2 months to ensure the residents receive the meal as per their preference. Audit findings will be reported to the monthly QAA for review and recommendations.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:
Based on policy review, observation, and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department.

Findings include:

Review of the facility's policy entitled, "Labeling and Dating," dated May 30, 2025, revealed that all staff were to ensure that food items that passed their use-by date were discarded.

Observations during the tour of the dietary department on October 21, 2025, at 10:21 a.m., revealed the following:

In the walk-in cooler, there were four cartons of milk with a use-by date of August 23, 2025, and four with a use-by date of October 9, 2025. There was a large pan of ham salad that was dated as prepared October 11, 2025, with a use-by date of October 17, 2025. There was a Styrofoam container with a resident's name on it dated with October 7, 2025, with French toast inside.

The microwave in the tray line section had dried food debris along the top of the inside.

In the walk in freezer, there were two cups of ice cream on the floor. In the dry storage room, there were ten pieces of plasticware and a packet of sugar on the floor where the food was stored.

In an interview on October 21, 2025, at 11:00 a.m., the Dietary Manager confirmed that the previously mentioned food items should have been removed and were not.

28 Pa. Code 201.14(a) Responsibility of licensee.

Plan of Correction - To be completed: 11/18/2025

1. The microwave was cleaned on 10/21/2025. The milk and ham salad was discarded on 10/21/2025. The floor was cleaned on 10/21/2025. Items in Styrofoam container were discarded when identified during survey.
2. An audit of the kitchen was completed to ensure that other products were labeled and dated as needed, the other appliances were cleaned appropriately, and other floor surfaces were cleaned appropriately throughout. No other variances were noted at the time of the audit.
3. Dietary Staff will be educated by NHA or designee, that floors need to be clean, microwave needs to be clean, and food products that are outdated or expired need to be discarded when identified.
4. A Quality Assurance and Performance Improvement plan will be developed. NHA or designee will complete random audits of the kitchen 2 times weekly for 4 weeks and then monthly for 2 months to ensure any expired or outdated products are discarded, floors free of excessive debris, or utilized equipment is clean. Audit findings will be reported to the monthly QAA for review and recommendations.

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