Cycle 1
Health 2024-05-03 · Fire 2024-05-03
10 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Little Falls, NY
Alpine Rehabilitation And Nursing Center
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
755 E Monroe Street, Little Falls, NY
(315) 823-0973
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
75
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Personal Healthcare Management
Operator or chain grouping
Approved since
1977-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.51
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.48
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.54
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
4.16
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,165
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.27
Composite VBP score used to determine payment impact.
Payment multiplier
0.9826
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.27
Baseline 19.81% · Performance 19.91% · Measure score 3.27 · Achievement 3.27 · Improvement 0
Healthcare-associated infections
0
Baseline 6.40% · Performance 9.22% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.89
Baseline 58.89% · Performance 51.85% · Measure score 2.89 · Achievement 2.89 · Improvement 1.57
Adjusted total nurse staffing
2.34
Baseline 3.37 hours · Performance 3.74 hours · Measure score 2.34 · Achievement 2.34 · Improvement 1.05
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.8% |
10.72%
3.1 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 20% · Lower 95% interval 9.75% |
| Discharge to community | 36.53% |
50.57%
14 pts worse
|
Worse than the National Rate · Eligible stays 62 · Observed rate 29.03% · Lower 95% interval 27.06% |
| Medicare spending per beneficiary | 1.15 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 92.98% |
95.27%
2.3 pts worse
|
Numerator 53 · Denominator 57 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 57 |
| Discharge self-care score | 40.91% |
53.69%
12.8 pts worse
|
Numerator 18 · Denominator 44 |
| Discharge mobility score | 36.36% |
50.94%
14.6 pts worse
|
Numerator 16 · Denominator 44 |
| Pressure ulcers or injuries, new or worsened | 10.53% |
2.29%
8.2 pts worse
|
Numerator 6 · Denominator 57 · Adjusted rate 9.78% |
| Healthcare-associated infections requiring hospitalization | 9.22% |
7.12%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 13.79% · Lower 95% interval 5.83% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 123 |
| Staff flu vaccination coverage | 55.64% |
42%
13.6 pts better
|
Numerator 74 · Denominator 133 |
| Discharge function score | 43.18% |
56.45%
13.3 pts worse
|
Numerator 19 · Denominator 44 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 10% |
25.2%
15.2 pts worse
|
Numerator 3 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.7
0.4 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.3 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
1.3
0.8 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.2 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
91.2%
7.3 pts better
|
93.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.6% · Q2 100.0% · Q3 100.0% · Q4 98.5% · 4Q avg 98.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
95.3%
3.3 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.0%
0.3 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.1% · Q3 3.3% · Q4 1.5% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
18.5%
18.5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 12.2% |
6.1%
6.1 pts worse
|
5.4%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 20.6% · Q3 8.5% · Q4 7.7% · 4Q avg 12.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.9% |
13.5%
2.6 pts better
|
19.6%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 9.5% · Q3 10.0% · Q4 9.1% · 4Q avg 10.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.9% |
14.8%
0.1 pts worse
|
16.7%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 14.0% · Q3 18.9% · Q4 16.7% · 4Q avg 14.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.2% |
15.1%
1.9 pts better
|
16.3%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 19.8% · Q3 9.5% · Q4 4.6% · 4Q avg 13.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.6% |
15.5%
2.9 pts better
|
14.9%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 14.3% · Q3 8.5% · Q4 15.2% · 4Q avg 12.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.4% |
0.6%
1.8 pts worse
|
1.0%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 4.9% · Q3 0.0% · Q4 1.1% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
1.4%
0.5 pts worse
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 1.7% · Q4 4.5% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.7% |
20.8%
3.9 pts worse
|
19.8%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 23.7% · Q3 25.6% · Q4 25.2% · 4Q avg 24.7% |
| Percentage of long-stay residents with pressure ulcers | 8.0% |
6.9%
1.1 pts worse
|
5.1%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 8.4% · Q3 9.6% · Q4 5.7% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 67.7% |
76.7%
9 pts worse
|
81.7%
14 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 81.5% · Q2 67.6% · Q3 64.0% · Q4 60.0% · 4Q avg 67.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.3% |
9.7%
1.4 pts better
|
12.0%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.3% · Observed 8.7% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.6% |
78.8%
2.8 pts better
|
79.7%
1.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.0% |
20.6%
3.6 pts better
|
23.9%
6.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.0% · Observed 19.6% · Expected 27.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-02-28 · Fire 2022-02-28
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-10-03 · Fire 2019-10-03
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-05-03
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-03
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-03
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-05-03
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-06-24
D · Potential for more than minimal harm
2022-02-28
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-04-04
D · Potential for more than minimal harm
2022-02-28
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2022-04-04
D · Potential for more than minimal harm
2022-02-28
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-04-04
D · Potential for more than minimal harm
2022-02-28
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-04-04
D · Potential for more than minimal harm
2022-02-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-04-04
D · Potential for more than minimal harm
2022-02-28
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-04-04
D · Potential for more than minimal harm
2022-02-28
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-04-04
E · Potential for more than minimal harm
2019-10-03
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2019-11-20
E · Potential for more than minimal harm
2019-10-03
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2019-11-20
D · Potential for more than minimal harm
2019-10-03
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-11-20
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-05-03
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-03
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-03
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-03
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-03
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-03
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-03
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-24
D · Potential for more than minimal harm
2023-07-15
F776 · Administration Deficiencies
Health
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Corrected 2023-09-04
E · Potential for more than minimal harm
2022-02-28
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-04-04
D · Potential for more than minimal harm
2022-02-28
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-04-04
D · Potential for more than minimal harm
2022-02-28
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-04-04
D · Potential for more than minimal harm
2022-02-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-04-04
D · Potential for more than minimal harm
2022-02-28
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-04-04
D · Potential for more than minimal harm
2022-02-28
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2022-04-04
D · Potential for more than minimal harm
2022-02-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-04-04
E · Potential for more than minimal harm
2019-10-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-20
D · Potential for more than minimal harm
2019-10-03
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-11-20
D · Potential for more than minimal harm
2019-10-03
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-11-20
Penalties and ownership
What sits behind the stars
Ownership
Zagelbaum, Ephraim
5% Or Greater Direct Ownership Interest · Individual
Zagelbaum, Yechiel
5% Or Greater Direct Ownership Interest · Individual
Barth, Alexander
5% Or Greater Direct Ownership Interest · Individual
Zagelbaum, Yoel
5% Or Greater Direct Ownership Interest · Individual
Amidon, Jeffrey
Operational/Managerial Control · Individual
Barth, Alexander
Corporate Officer · Individual
Macri, Deandra
Operational/Managerial Control · Individual
Zagelbaum, Ephraim
Corporate Director · Individual
Nearby options
Other facilities in reach
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Foltsbrook Center For Nursing And Rehabilitation
Herkimer, NY
1-star overall rating with 2-star inspections with 9 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
#2
Valley Health Services Inc
Herkimer, NY
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
St Johnsville Rehabilitation And Nursing Center
Saint Johnsville, NY
2-star overall rating with 2-star inspections with 12 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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