Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident's controlled medication, scheduled for destruction, was misappropriated when a Housekeeping Supervisor removed a blister pack from a conference room, consumed several pills, and discarded the remainder in another resident's room. The staff member later admitted to the act after an internal investigation and staff interviews confirmed the misappropriation.
Surveyors observed that staff did not label or date several pre-made salads and containers of orange liquid stored in the walk-in refrigerator. Dietary staff and the kitchen manager confirmed that these items should have been labeled and dated according to facility policy, but this was not done, potentially affecting all residents.
Surveyors found that staff did not consistently date medications upon opening or discard expired medications, including eye drops and oral medications, for multiple residents with chronic conditions. LPNs confirmed that several opened medications were undated and some were expired, contrary to facility policy requiring dating and timely disposal.
A resident with multiple chronic conditions, including severe cognitive impairment and total dependence for ADLs, was admitted to hospice care. The facility did not complete the required significant change MDS assessment within the mandated 14-day period, as confirmed by the MDS Coordinator and facility records.
A resident with aphasia, dementia, and atrial fibrillation did not have their MDS assessments completed or transmitted within the required timeframe. Both the January and April assessments were completed and submitted late, as confirmed by the MDS Coordinator.
A resident with multiple diagnoses, including COPD and dementia, was ordered to receive oxygen therapy as needed, but this treatment was not accurately documented in the MDS assessment. The MDS Coordinator confirmed the omission, which was inconsistent with facility policy requiring accurate completion and certification of MDS sections.
Staff did not monitor or document gastric residual volumes for a resident with a feeding tube, despite physician orders and facility policy requiring checks before each feeding. The lack of documentation and monitoring was confirmed by the ADON, and the resident's care plan included specific interventions related to tube feeding management.
A medication error rate above 5% was identified when an LPN administered Humalog and Glargine insulin to a resident with diabetes without priming the insulin pens as required by manufacturer guidelines. This resulted in two errors out of 29 opportunities, exceeding the acceptable threshold for medication errors.
A resident with diabetes and other medical conditions received Humalog and Glargine insulin injections from an LPN who did not prime the insulin pens as required by manufacturer guidelines. The LPN confirmed the omission, resulting in a significant medication error during administration.
Staff failed to perform proper hand hygiene during medication administration for a resident, did not clean a glucometer after use for another resident, and left a used disposable gown in the room of a resident on enhanced barrier precautions. These actions were not in accordance with facility policies and CDC guidance, as confirmed by staff interviews and policy review.
A resident with multiple diagnoses and intact cognition experienced an ongoing ant infestation in his room, which he reported to the facility without receiving a response. Observations confirmed the presence of ants on multiple occasions, and the Maintenance Director acknowledged the issue, noting that only an outside pest control company could provide treatment as per facility policy.
A resident with multiple chronic conditions experienced five days without a bowel movement, during which time staff failed to implement constipation interventions or update the care plan. Despite complaints of abdominal pain and reports from therapy staff, no stool softeners were prescribed until after physician notification, and bowel assessments were not consistently performed. The resident was later hospitalized with fecal impaction and colitis, and facility leadership confirmed gaps in assessment and protocol implementation.
A resident with multiple comorbidities and bladder incontinence developed UTI symptoms but did not receive timely antibiotic treatment, as lab results were delayed and there was no documented monitoring or intervention for bladder issues. The resident was later hospitalized with significant bladder distention and renal pelvictasis, and facility leadership confirmed a lack of timely assessment and care.
Surveyors identified that several residents received meals that were tough, overcooked, mushy, or bland, with staff acknowledging that food was intentionally overcooked to meet temperature requirements. Multiple residents expressed dissatisfaction with the taste and texture of their meals, indicating a failure to provide palatable and properly prepared food as required by facility policy.
A facility failed to perform incontinence care in a sanitary manner for a resident with cognitive impairment and multiple health issues. Two CNAs did not change gloves after completing care on the resident's buttocks/sacrum area and continued to handle the resident and her belongings without washing hands, contrary to facility policy.
The facility failed to implement its abuse policy by allowing a CNA to work without timely completion of a background check. The CNA was hired and continued to work beyond the 30-day period without the facility receiving her fingerprint background check results. This oversight had the potential to affect all 67 residents. The facility's policy requires background checks for all employees, but this was not adhered to, as confirmed by the HR Director.
The facility failed to provide a safe environment when a window air-conditioning unit in the dining room was found with exposed wires and coils, covered in dust and debris. Housekeeping and maintenance staff were unsure of the hazard risk or when the unit was last maintained. The Administrator confirmed the absence of a facility policy regarding the air conditioning system and thermostat controls.
A resident with multiple medical conditions was unable to access his call light, which was found behind his bed and out of reach. The facility's policy requires call lights to be within reach, but this was not adhered to, preventing the resident from calling for assistance.
Failure to Prevent Misappropriation of Resident Medication
Penalty
Summary
A deficiency occurred when the facility failed to prevent the misappropriation of a resident's controlled medication. A cognitively intact resident with multiple diagnoses, including congestive heart failure, schizoaffective disorder, generalized anxiety disorder, and chronic pain syndrome, had been dispensed hydrocodone-acetaminophen tablets. The controlled substance administration record indicated a discrepancy in the number of tablets remaining, and a subsequent review revealed that a blister pack containing the medication, which was scheduled for destruction, had gone missing. An investigation found that the Housekeeping Supervisor removed the blister pack from a plastic bag in the conference room, took several pills, and then discarded the remaining blister pack in another resident's room. The Housekeeping Supervisor later admitted to taking the medication and attempting to conceal the act by pretending to have found the blister pack. The incident was confirmed through staff interviews and review of facility records.
Failure to Label and Date Food Items in Refrigeration
Penalty
Summary
Staff failed to ensure that food items stored in the walk-in refrigerator were properly labeled and dated, as required by facility policy. On two separate occasions, surveyors observed multiple pre-made salads and pitchers or trays containing orange liquid that were not labeled or dated. Dietary staff and the kitchen manager both confirmed during interviews that these items should have been labeled and dated upon opening, in accordance with the facility's Food Receiving and Storage policy dated November 2022. This deficiency had the potential to affect all 69 residents in the facility, as proper labeling and dating of food is necessary to ensure food safety.
Failure to Date and Discard Medications as Required
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly dated upon opening and discarded by their expiration dates, as required by professional standards and facility policy. During observations and medical record reviews, multiple instances were identified where opened medications, including various eye drops and insulin, were not dated upon opening for several residents with diagnoses such as diabetes, chronic kidney disease, heart failure, COPD, and glaucoma. Additionally, expired medications, such as Refresh liquid gel eye drops and docusate sodium, were found in use or available for administration. Licensed Practical Nurses confirmed during interviews that these medications were either not dated or had expired and should have been discarded. The deficiency affected at least eight residents and had the potential to impact all 69 residents in the facility. The facility's own policy required staff to record the date when opening multi-dose containers and to check expiration dates before administering medications. Despite this, observations revealed that staff did not consistently follow these procedures, resulting in the presence of undated and expired medications in medication carts and storage areas.
Failure to Complete Timely Significant Change MDS Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment within the required 14-day timeframe for a resident who was admitted to hospice care. The resident, who had a history of multiple sclerosis, cerebral infarction, and vascular dementia, was noted to have severely impaired cognition and required total assistance with activities of daily living (ADLs). Record review showed that the significant change MDS assessment was not completed in a timely manner following the hospice admission order, as confirmed by the MDS Coordinator. Facility policy required comprehensive assessments to be conducted according to the timeframes established in the Resident Assessment Instrument (RAI) manual.
Failure to Submit MDS Assessments Timely
Penalty
Summary
The facility failed to submit Minimum Data Set (MDS) assessments in a timely manner for one resident out of 17 reviewed. The resident, who had diagnoses including aphasia, dementia, and atrial fibrillation, was admitted on 10/03/23. Review of the medical record showed that the MDS assessment for January had a target date of 01/06/25 but was not completed until 01/27/25, and the April assessment had a target date of 04/07/25 but was not completed until 04/29/25. Staff interview with the MDS Coordinator confirmed that both assessments were completed late and were not transmitted within the required 14-day timeframe.
Inaccurate Coding of Oxygen Therapy on MDS Assessment
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were coded accurately for one resident. Medical record review showed that the resident was admitted with diagnoses including cerebral infarction, COPD, dementia, and anxiety disorder. Physician orders indicated the resident was to receive oxygen therapy as needed to maintain oxygen saturation above 92%. However, review of the MDS assessment did not reflect the resident's use of oxygen therapy in section O, which documents special treatments and procedures. This discrepancy was confirmed by the MDS Coordinator, who acknowledged that the assessment was not coded correctly. Facility policy requires that licensed nurses accurately complete and certify each section of the MDS assessment.
Failure to Monitor and Document Tube Feeding Residuals
Penalty
Summary
Staff failed to monitor and document tube feeding residuals for a resident with a feeding tube, despite a physician's order requiring residuals to be checked before each feeding. The order specified that if the residual was above 60 milliliters, feeding should be held for one hour and rechecked, and if still elevated, the physician should be notified. The resident's care plan also included interventions for administering enteral feedings as ordered, checking tube placement, flushing the tube, and notifying the physician for increased residuals. Medical record review showed no documentation of tube feeding residuals being checked for the resident during the specified period. This was confirmed by the Assistant Director of Nursing, who acknowledged the absence of documentation despite the existing physician's order. Facility policy required staff to measure and record gastric residual volume to assess feeding tolerance and minimize aspiration risk, but this was not followed for the resident in question.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Insulin Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required. During a review of medication administration, two errors were identified out of 29 opportunities, resulting in a 6.9% error rate. Specifically, a resident with diagnoses including type two diabetes mellitus, generalized anxiety disorder, and peripheral vascular disease was involved. The resident had intact cognition and required staff assistance with activities of daily living. On the observed date, an LPN administered 22 units of Humalog insulin and 54 units of Glargine insulin to the resident without priming the insulin pens prior to administration. The LPN confirmed in an interview that she did not perform the priming step. Manufacturer guidelines for both types of insulin require priming the pen before each injection to ensure proper dosing and function. Failure to follow these guidelines led to the medication administration errors identified during the survey.
Failure to Prime Insulin Pens Prior to Administration
Penalty
Summary
A review of the medical record, observation, and staff interview revealed that a resident with diagnoses including type two diabetes mellitus, generalized anxiety disorder, and peripheral vascular disease was not free from significant medication errors. The resident, who had intact cognition and required staff assistance with activities of daily living, had physician's orders for Humalog insulin 22 units subcutaneously before meals and Glargine insulin 54 units subcutaneously in the morning. On the observed date, an LPN administered both Humalog and Glargine insulin to the resident without priming the insulin pens prior to administration. The LPN confirmed during interview that she did not perform the priming step. Manufacturer's guidelines for both types of insulin specify that priming the pen is necessary before each injection to ensure proper dosing and function, but this step was omitted during the medication administration.
Infection Control Lapses in Hand Hygiene, Equipment Cleaning, and PPE Disposal
Penalty
Summary
Staff failed to follow infection prevention and control protocols in several instances. An LPN did not perform hand hygiene before or after administering medication to a resident with schizoaffective disorder, type two diabetes mellitus, and anxiety disorder, despite facility policy requiring hand hygiene before and after routine resident care. In another case, the same LPN did not clean a glucometer after use for a resident with chronic obstructive pulmonary disease, type two diabetes mellitus, and congestive heart failure, contrary to facility policy that mandates adherence to infection control procedures during medication administration. Additionally, a resident with type two diabetes mellitus, congestive heart failure, and chronic obstructive pulmonary disease, who was on enhanced barrier precautions due to venous/stasis ulcers, had a used disposable gown left on an entry table in their room. The LPN responsible confirmed the gown was not discarded after use, and the ADON verified that gowns should be disposed of after each use according to facility policy and CDC guidance. These deficiencies were identified through medical record review, observation, staff interviews, and policy review.
Failure to Address Ant Infestation in Resident Room
Penalty
Summary
The facility failed to ensure that resident rooms were free from pests, specifically ants, as required by their pest control policy. A resident with muscular dystrophy, depression, and opioid dependence, who had intact cognition and required supervision with activities of daily living, was observed to have ants present in his room on two separate occasions. The resident reported that ants had been present for weeks and that he had notified the facility, but no action had been taken to address his concern. The Maintenance Director confirmed the presence of ants and stated that only an outside pest control company could perform treatments, in accordance with facility policy. Review of the facility's pest control policy indicated that an outside company was responsible for monthly and emergency pest treatments.
Failure to Prevent and Manage Constipation Resulting in Fecal Impaction
Penalty
Summary
The facility failed to ensure that a resident was free from constipation and did not implement appropriate interventions to prevent constipation, as required by physician orders and the resident's care plan. The resident, who had multiple diagnoses including metabolic encephalopathy, coronary artery disease, heart failure, hypertension, peripheral vascular disease, thyroid disorder, and osteoporosis, was admitted and later discharged after experiencing a significant episode of constipation. The baseline care plan identified the resident as at risk for bowel and bladder issues, but there were no updates or specific interventions added to address constipation. Despite the facility's standing physician orders for constipation management, which included the use of Milk of Magnesia and notification of the physician if there was no bowel movement, the resident did not have any stool softeners or standing orders for constipation on the Medication Administration Record. Documentation showed that the resident did not have a bowel movement for five days, during which time therapy staff reported complaints of stomach pain and constipation to nursing staff. The physician was eventually notified and prescribed a stool softener, after which the resident had several small and large bowel movements, but no further bowel assessments were completed. Subsequently, the resident experienced increased respiratory rate, low oxygen saturation, and was sent to the hospital, where a rectal fecal impaction and colitis were diagnosed. Interviews with facility leadership and the medical director confirmed that there was a lack of ongoing bowel assessments after the initial intervention, and that the only bowel protocol in place was for Milk of Magnesia, which was not administered prior to physician notification. The medical director also indicated that she was not fully informed of the duration of the resident's constipation and expected more thorough nursing assessments during the period in question.
Delayed UTI Treatment and Inadequate Bladder Monitoring Result in Resident Harm
Penalty
Summary
A deficiency occurred when a resident exhibiting signs and symptoms of a urinary tract infection (UTI) was not treated in a timely manner. The resident, who had a history of multiple medical conditions including metabolic encephalopathy, coronary artery disease, heart failure, hypertension, peripheral vascular disease, thyroid disorder, and osteoporosis, was identified as being at risk for bladder incontinence and was incontinent of bladder. Despite these risk factors, the care plan was not updated beyond the baseline, and there were no interventions documented for bladder incontinence. On a specific date, the resident began to show symptoms of a UTI, including foul-smelling urine, burning during urination, and abdominal pain. The physician was notified, and orders for a urinalysis (UA) with culture and sensitivity (C&S) were placed. Although the urine sample was collected and the order was changed to STAT for immediate pickup, the laboratory results were not reported back to the facility until several days later. During this period, there was no documentation or monitoring of the resident for bladder issues, and no interventions were implemented to address her incontinence or potential urinary retention. The resident did not receive antibiotic treatment for the UTI until six days after the initial symptoms were observed. She was subsequently transferred to the hospital, where it was discovered that she had significant bladder distention with renal pelvictasis. Interviews with facility leadership confirmed that there was a lack of timely intervention and monitoring for bladder issues, and the medical director indicated that nursing staff should have assessed for bladder distention during the period in question. The facility's own policy outlined the need for prompt assessment, monitoring, and treatment of UTIs, which was not followed in this case.
Failure to Provide Palatable and Properly Prepared Meals
Penalty
Summary
Surveyors found that the facility failed to ensure meals were palatable, affecting three residents reviewed for food. Observations included a lunch meal consisting of a peppered hamburger patty, buttered noodles, green beans, and white cake. A test tray revealed the meat was crispy around the edges and tough, the noodles were overcooked and mushy, and the green beans were bland. The Dietary Manager acknowledged that the noodles were intentionally cooked softer due to resident complaints about hardness, but admitted the foods were overcooked to achieve the required temperature for the beef patties. Resident interviews confirmed dissatisfaction with the meal quality. One resident stated the noodles and beef patty were overdone, another described the food as processed, tough, and unappetizing, and a third resident complained about the meat being tough and referred to it as 'mystery meat,' also noting the noodles were mushy and fish was hard when served. The facility's policy on food palatability emphasized serving meals that are nutritious, safe, and acceptable in taste, appearance, and texture, but these standards were not met during the observed meal service.
Incontinence Care Deficiency
Penalty
Summary
The facility failed to perform incontinence care in a sanitary manner for Resident #19, who was admitted with diagnoses including cerebral infarction, hypertensive heart disease with heart failure, and obesity. The resident had moderate cognitive impairment and required substantial assistance with personal hygiene and was dependent on staff for toileting hygiene. During an observation, two CNAs performed incontinence care on the resident but did not change their gloves after completing the care on the resident's buttocks/sacrum area. They continued to wear the same gloves while repositioning the resident, covering her with blankets, handing her the call light, and handling her oxygen tubing. Interviews with the CNAs confirmed that they did not change their gloves or wash their hands after completing incontinence care, which was against the facility's Perineal Care procedure. The facility's policy required staff to remove soiled gloves and wash hands before repositioning and covering the resident, and before handling items such as the call light and oxygen tubing. This deficiency was identified during a complaint investigation and was documented under Complaint Number OH00159419.
Failure to Implement Timely Background Checks for CNA
Penalty
Summary
The facility failed to implement its abuse policy effectively, as evidenced by the hiring and continued employment of a Certified Nursing Assistant (CNA) without timely completion of a background check. CNA #120 was hired on April 3, 2024, but her fingerprint background check was not completed until May 3, 2024, with the results received by the facility on May 13, 2024. Despite the delay in receiving the background check results, CNA #120 continued to work at the facility from May 3, 2024, through May 13, 2024, which was beyond the 30-day period from her hire date. This oversight had the potential to affect all 67 residents residing in the facility. The facility's policy, dated August 10, 2023, mandates that background checks be conducted for all employees in accordance with state law and facility policy. However, the facility did not adhere to this policy, as confirmed by the Human Resource Director during an interview. This deficiency was identified during a complaint investigation and highlights a lapse in the facility's procedures to prevent abuse, neglect, and exploitation.
Unsafe Air Conditioning Unit in Dining Room
Penalty
Summary
The facility failed to provide a safe environment for residents when a window air-conditioning unit in the dining room was found with exposed wires and coils. Observations revealed that the unit was plugged into an electrical outlet and covered with a thick layer of dust, debris, and cobwebs. A thermostat on the wall had a typed note warning not to change the settings to avoid overheating and potential fire hazards. Housekeeping staff confirmed the unit had been in this condition for a long time and was unsure of the hazard risk or when it was last cleaned or maintained. The facility census was 71, and 41 residents identified as cognitively impaired and mobile were potentially affected by this deficiency. Interviews with the Administrator and Maintenance Staff confirmed the non-functioning status of the air conditioning unit and the absence of a facility policy regarding the air conditioning system and thermostat controls. The Administrator was unaware of the origin of the warning note and removed it during the interview. Maintenance Staff verified the unit posed an electrical risk due to the exposed wires and coils and was unsure when the unit was last maintained. This deficiency was investigated under Complaint Number OH00153796.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that residents had access to their call light, affecting one resident (Resident #200) out of two reviewed for call light accessibility and functioning. Resident #200, who had diagnoses including right hip fracture, seizure disorder, left below the knee amputation, traumatic brain injury, and vascular dementia, required substantial assistance for various activities of daily living. The plan of care for Resident #200 included having commonly used articles within easy reach, such as the call light. During an interview and observation, Resident #200 stated he was unable to find his television remote and could not call for help because he did not have his call light. The call light was found by RN #31 behind the resident's bed, approximately five feet up the wall on a light bar, making it inaccessible to the resident. RN #31 confirmed that call lights were supposed to be within reach of residents and verified that Resident #200's call light was not within reach, preventing him from calling for assistance. The facility's policy on call lights, revised in January 2020, mandates that staff ensure the call light is within reach of the resident before leaving the room.
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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.
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Nursing homes near Xenia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Atrium Nursing And Rehabilitation | 0 mi | ★★★★★ | 8 | 0 |
| Xenia Health And Rehab | 0.2 mi | ★★★★★ | 1 | 0 |
| Overbrook Landing Health And Rehabiliation | 1.5 mi | — | 0 | 0 |
| Trinity Community | 6.7 mi | ★★★★★ | 0 | 0 |
| Friends Extended Care Center | 6.9 mi | ★★★★★ | 10 | 0 |
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