Health inspection·April 8, 2025

F 0684 Level of Harm - Actual harm Review of the physician progress note dated 03/11/25 for Resident #75 documented the physician came into the facility and determined the chief complaint was an overall decline. There were also concerns of constipation and straining with bowel movements. There was an order for Sennosides-Docusate Sodium 8.6-50 milligrams (mg) to give two tablets one time a day for constipation. Residents Affected - Few Review of the MAR for Resident #75 from 03/12/25 through 03/15/25 revealed the Senna was given to the resident. Review of the bowel tracker on 03/12/25 revealed Resident #75 had a small bowel movement, on 03/13/25 she had two small bowel movements, and on 03/14/25 she had two large bowel movements. Review of the progress notes from 03/12/25 through 03/15/25 revealed there were no further bowel assessments completed. Review of progress note dated 03/15/25 at 10:00 A.M. documented Resident #75's breathing had increased. Her respirations were 22 breaths per minute, blood pressure 140/80 millimeters of mercury (mmHg), pulse 110 beats per minute, and oxygen saturation was 83 percent (%). Oxygen was applied. The family was notified and wanted the resident sent out to the hospital for evaluation. Review of the hospital records dated 03/15/25 revealed a rectal fecal impaction with thickening of the rectal wall extending proximately into the splenic flexure suggestive of superimposed colitis. Liquefied small bowel enteric content with foci of air in the nondependent bowel right upper quadrant. A soap suds enema was ordered. During an interview on 04/08/25 at 9:45 A.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) stated they knew about the unconfirmed impacted bowel from the family, and they started an action plan. They confirmed something happened between 03/11/25 when the doctor reported she had normal bowel sounds and a soft abdomen until 03/15/25 when the resident went out to the hospital. They confirmed there weren't any bowel assessments completed after 03/11/25 since the resident was having bowel movements. They confirmed the only bowel protocol the facility had in place was for milk of magnesia and Resident #75 wasn't given any of that before letting the doctor know on 03/11/25. They confirmed Resident #75 wasn't getting any stool softeners before 03/11/25. During an interview on 04/08/25 at 12:47 P.M., Medical Director (MD) #200 stated she had been notified of Resident #75's constipation but didn't know the constipation had been going on for five days. She stated when she saw Resident #75 on 03/11/25 she assessed her bowel sounds and abdomen and didn't find anything abnormal. She stated she ordered a stool softener and didn't hear back from the facility. She did not know the resident was found to be impacted on 03/15/25 at the hospital and stated the symptoms the resident had upon leaving for the hospital on [DATE] with an increased heart rate could have been from her bowel impaction. She stated she would expect to see nursing doing bowel assessments to ensure there wasn't any problems from 03/11/25 through 03/15/25 and not just think because the resident was having bowel movements she was ok. Review of the policy titled Constipation Management Policy, dated 09/10/24 revealed to provide guidelines for the prevention, identification, and management of constipation to ensure patient comfort and health. Prevention (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365601 If continuation sheet Page 2 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Nursing and Rehabilitation Center 164 Office Park Drive Xenia, OH 45385 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 1. Hydration: Encourage patients to drink fluids with each meal/Med pass on an as needed basis, Level of Harm - Actual harm unless contraindicated. Residents Affected - Few 2. Exercise: Recommend regular physical activity to stimulate bowel function as able 3. Routine: Establish regular bowel habits by encouraging patients to use the restroom as able Identification 1. Monitor: Regularly assess patients for signs of constipation. 2. Documentation: Record bowel movement in the patient's medical record, plan of care or activities of daily living flowsheets. Management 1. Initial Interventions: Increase fluid intake with meals/Med Pass, unless contraindicated Encourage physical activity as able 2. Medications: standing orders to be implemented per each facility protocol Bulk-forming agents: e.g., psyllium Osmotic laxatives: e.g., polyethylene glycol Stimulant laxatives: e.g., Bisacodyl (use sparingly) Monitoring and Follow-Up 1. Regular Monitoring: Track patient progress and adjust treatment plans as necessary. Each facility may implement a system for monitoring that best suits their workflow. 2. Patient Education: Provide education on lifestyle modifications and the importance of adherence to treatment plans. The deficient practice was corrected on 04/02/25 when the facility implemented the following corrective actions: • On 03/17/25 and 04/01/25, all resident records were audited to see if they had a bowel movement documented and if not, they initiated their bowel protocol which was to give milk of magnesia 30 ml and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365601 If continuation sheet Page 3 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Nursing and Rehabilitation Center 164 Office Park Drive Xenia, OH 45385 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 if no bowel movement, then call the doctor. Auditing is still in progress. Level of Harm - Actual harm • Residents Affected - Few Review of the medical records for Residents #18, #4, and #51 revealed they had a bowel tracker in place since 03/17/25 and they didn't have any concerns for constipation in the progress notes. They all had a care plan in place for bowels. • On 03/26/25, the nursing staff were educated on abdominal assessment and bowel documentation and there was a video to watch on bowel assessment. • During an interview on 04/08/25 at 11:20 A.M., Licensed Practical Nurse (LPN) #122 stated she had been educated on bowel assessment which was a video and on documentation of the bowel tracker. • During an interview on 04/08/25 at 11:23 A.M., LPN #201 stated she had been educated on bowel assessment which was a video and on documentation of the bowel tracker. This deficiency represents non-compliance investigated under Complaint Number OH00163923. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365601 If continuation sheet Page 4 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Nursing and Rehabilitation Center 164 Office Park Drive Xenia, OH 45385 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of hospital records, staff interview, and review of facility policy, the facility failed to ensure residents were treated timely for a urinary tract infections (UTI). This resulted in Actual harm when Resident #75 developed signs and symptoms of a UTI and wasn't treated for the UTI for six days. She transferred out to the hospital and it was discovered the resident had a significant distention in the bladder with renal pelvictasis, (renal pelviectasis, is when urine gathers in the center of the kidney, called the pelvis. This makes the kidney larger than normal. This condition can affect one or both kidneys.) This affected one (Resident #75) of one resident reviewed for UTI. There were no other residents in the facility with a UTI. The census was 73. Findings include: Record review revealed Resident #75 was admitted on [DATE] and discharged on 03/15/25. Diagnoses included metabolic encephalopathy, coronary artery disease, heart failure, hypertension, peripheral vascular disease, thyroid disorder and osteoporosis. Review of the baseline care plan dated 01/18/25 for Resident #75 revealed she was at risk for bladder incontinence and was incontinent of bladder. There were no further updates to the care plan. Review of the admission Minimum Data Set (MDS) assessment, dated 01/24/25, documented Resident #75 was moderately cognitively impaired. She required supervision/touching assistance for eating, substantial/maximal assistance for toileting, bed mobility, and transfers. She was always continent for bowel and incontinent for bladder. Review of progress note dated 03/07/25 at 6:13 A.M. revealed Resident #75 had foul-smelling urine, burning while urinating, and pain in the abdominal region. The physician was called and made aware with new orders for a urinalysis (UA) with Culture and Sensitivity (C&S). The order was put in the computer system at 8:59 P.M. Review of progress notes dated 03/08/25 at 2:31 P.M. documented the UA and C&S were obtained and the order was changed to STAT (immediate) pickup. At 3:19 P.M. a call was made to the laboratory (lab) to make sure the urine sample was going to be picked up on this day and the lab assured the facility that a representative would be at the facility on that evening to pick up the sample. Review of the pickup time revealed it was 3:19 P.M. The lab results were not reported back to the facility until 03/12/25 at 1:48 P.M. Review of the physician orders dated 03/13/25 at 5:53 A.M. revealed Macrobid 100 milligrams (mg) to give one two times a day for five days. This was started on 03/13/25. The resident was sent to the hospital on [DATE] for a fecal impaction. Review of the hospital records dated 03/15/25 revealed Resident #75 had a significant distention in the bladder with renal pelvictasis left greater than the right and no obstruction was noticed. She also tested positive for Influenza A. During an interview on 04/08/25 at 9:45 A.M. the Director of Nursing (DON) and the Assistant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365601 If continuation sheet Page 5 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Nursing and Rehabilitation Center 164 Office Park Drive Xenia, OH 45385 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Actual harm Residents Affected - Few Director of Nursing (ADON) stated they thought the facility executed the orders for the UA and C&S in a timely manner even though it took six days to get the resident an antibiotic and she was exhibiting signs and symptoms of a UTI. They confirmed there wasn't any interventions for the incontinence of bladder. They also confirmed there wasn't any documentation or monitoring of the resident for bladder issues from 03/11/25 through 03/15/25. During an interview on on 04/08/25 at 12:47 P.M., Medical Director (MD) #200 revealed she had no idea the hospital found a significant distention of Resident #75's bladder. She reported it could take up to four days to get the result of a UA and C&S because the UA was just a dip and the C&S was what took the longest to get a result. She revealed when she saw the resident on 03/11/25 she did an assessment on her abdomen and flanks, but there wasn't anything abnormal. She reported the expectation of the nursing staff would be do an assessment on the resident for a distended bladder between 03/11/25 through 03/15/25. She revealed just because the resident was urinating, had a UTI and was on antibiotics for the UTI didn't mean she was ok. She revealed the increased heart rate upon discharge to the hospital on [DATE] could have been from the distension of the bladder. Review of policy titled Urinary Tract Infection/Bacteremia, dated 2001, revealed: Assessment and Recognition 1. The physician and staff will identify individuals with a history of symptomatic urinary tract infections, and those who have risk factors (for example, an indwelling urinary catheter, kidney stones, urinary outflow obstruction, etc.) for UTl. 2. The staff and practitioner will identify individuals with possible signs and symptoms of a UTI. a. Signs and symptoms of a UTI may be specific to the urinary tract and/or generalized. The presentation of symptomatic UTl varies. b. Nurses should observe, document, and report signs and symptoms (for example, fever or hematuria) in detail and avoid premature diagnostic conclusions. c. New onset of nonspecific or general symptoms alone (change in mental status, decline in appetite, etc.) is not enough to diagnose a UTI. Urine odor, color and clarity also are not adequate to indicate bacteruria or a UTI. d. Acute deterioration in previously stable chronic urinary symptoms may indicate an acute infection. Multiple concurrent findings such as fever with hematuria or catheter obstruction are more likely to be due to a urinary source. e. A positive urine culture in someone with chronic genitourinary symptoms is not enough to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365601 If continuation sheet Page 6 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Nursing and Rehabilitation Center 164 Office Park Drive Xenia, OH 45385 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 diagnose a symptomatic UTI. The presence of either pyuria or a positive leukocyte esterase test Level of Harm - Actual harm alone are not enough to prove that the individual has a UTI, but the absence of pyuria or a Residents Affected - Few negative leukocyte esterase test is fairly strong evidence that a UTI is not present. Cause Identification 1. The physician will help nursing staff interpret any signs, symptoms, and lab test results. Diagnosis must be based on the entire picture and not just on one or several findings in isolation. a. Before diagnosing a UTI or urosepsis and ordering antibiotics, the physician should consider a resident's overall picture including specific evidence that helps confirm or refute the diagnosis of a UTI (as discussed above). 2. The physician will help identify causes of, and factors contributing to, bacteruria or UTl such as bladder outlet obstruction, kidney stones, neurological impairments, and medications that can cause urinary retention. 3. Because nonspecific or systemic symptoms can be due to diverse factors either instead of or along with a UTI, the staff and practitioner will also consider additional or alternative causes regardless of whether bacteruria or urinary symptoms is present. a. For example, a patient with a UTI could also have confusion caused by fluid and electrolyte imbalance such as hypernatremia as a result of several days of inadequate food and fluid intake. Treatment/Management 1. The physician will order appropriate treatment for verified or suspected UTl and/or urosepsis based on a pertinent assessment. a. Empirical treatment should be based on a documented description of an individual's symptoms and on consideration of relevant test results, co-existing illnesses and conditions, and pertinent risk factors. b. Generally, symptomatic UTl should be treated. Bacteruria alone (an asymptomatic UTI) should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365601 If continuation sheet Page 7 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Nursing and Rehabilitation Center 164 Office Park Drive Xenia, OH 45385 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 not be treated routinely, because treating it does not materially change outcomes, improve Level of Harm - Actual harm longevity, or correct underlying problems. Residents Affected - Few c. In select situations, empirical antimicrobial therapy may be warranted if urosepsis or other complications are suspected. d. In select situations, empirical antimicrobial therapy may be warranted for afebrile individuals with non-specific symptoms. 2. The physician will not treat asymptomatic individuals whose urine is colonized with yeast or with multi-resistant organisms such as methicillin-resistant Staphylococcus aureus or Enterococcus without careful review and clinical rationale. 3. The physician should consider stopping antibiotics or switching parenteral to oral antibiotics in individuals with uncomplicated UTl who have been afebrile and asymptomatic for at least 48 hours. 4. The physician will help the staff identify suspected sepsis related to a UTI and identify whether hospitalization may be warranted. 5. Fever and change in mental status alone do not automatically warrant hospitalization, nor is there compelling evidence that hospitalization improves the ultimate outcomes in individuals with symptomatic UTl. Sepsis, however, may sometimes warrant more aggressive inpatient treatment. Monitoring 1. The physician and nursing staff will review the status of individuals who are being treated for a UTI and adjust treatment accordingly. a. Decisions should be made primarily on the basis of clinical signs and symptoms. The goal of treatment in most cases is to control signs and symptoms of infection, not to eliminate bacteruria. b. Follow-up urine cultures after antibiotic treatment are not indicated routinely, but may be helpful if the symptoms are not resolving or complications are present. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365601 If continuation sheet Page 8 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Nursing and Rehabilitation Center 164 Office Park Drive Xenia, OH 45385 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 2. When a resident has a persistent or recurrent urinary tract infection after treatment with Level of Harm - Actual harm antibiotics, the physician will review the situation carefully with the nursing staff and consider Residents Affected - Few other or additional issues (such as urinary obstruction or indwelling catheter change or removal) before prescribing additional courses of antibiotics. a. Physicians should justify continuing or resuming antibiotic treatment beyond an initial course. This deficiency represents non-compliance investigated under Complaint Number OH00163923. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365601 If continuation sheet Page 9 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Nursing and Rehabilitation Center 164 Office Park Drive Xenia, OH 45385 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews and policy review, the facility failed ensure meals were palatable. This affected three (Residents #31, #59 and #57) of three residents reviewed for food. The facility identified two residents who couldn't eat anything by mouth. The census was 73. Residents Affected - Few Findings include: Review of the menu dated 04/07/25 revealed lunch consisted of a peppered hamburger patty, buttered noodles, green beans, and white cake. A test tray was obtained on 04/07/25 at 11:50 A.M. The meat was crispy around the edges and was tough. The noodles were over cooked and tasted mushy and the green beans were bland. During an interview on 04/07/25 at 11:55 A.M., Dietary Manager (DM) #171 stated if she cooks the noodles el [NAME], the residents complain they are too hard. This is the way the residents like the noodles. Se said to get the beef pepper patties done and up to temperature they had to be cooked this way. She admitted the foods were over cooked. During an interview on 04/07/25 at 12:55 P.M., Resident #57 stated the buttered noodles and the peppered beef patty were too done at lunch time. During an interview on 04/07/25 at 1:07 P.M., Resident #21 at 1:07 P.M. stated she had a chef salad for lunch but didn't like the food. The food was processed, tough, and didn't taste very good. During an interview on 04/07/25 at 1:15 P.M., Resident #39 stated the food sucked. She said the meat was tough and she called it the mystery meat because it was processed. She stated the noodles for lunch were mushy. She stated when fish was served, it was hard. Review of policy titled Food Palatability, not dated, revealed the facility was committed to serving nutritious, safe, and palatable meals to residents that reflect their choices, cultural backgrounds, and dietary restrictions. Meals will be served in a manner that promotes dignity, socialization, and enjoyment of the dining experience. Palatability is food that is acceptable in taste, appearance, and texture to the resident. This deficiency represents non-compliance investigated under Complaint Number OH00164115. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365601 If continuation sheet Page 10 of 10