Health inspection·August 29, 2022

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the Preadmission Screening and Resident Review, and staff interview, the facility failed to update a resident's Preadmission Screening and Resident Review (PASARR) when a new diagnosis of schizophrenia was added. This affected one resident (#28) out of three residents reviewed for PASARR. The facility census was 63. Review of Resident #28 medical record revealed he was admitted to the facility on [DATE]. Diagnoses included dizziness and giddiness, history of traumatic brain injury, vascular dementia with behavioral disturbance, type II diabetes, post traumatic stress disorder, depression, phobic anxiety disorder, acquired absence of right leg below knee, hypertension, and epilepsy. On 08/07/19 a new diagnosis of schizophrenia was added to his diagnosis. Review of the quarterly Minimal Data Set (MDS) dated [DATE] revealed Resident #28 was cognitively intact. His functional status was listed as limited to extensive one person assistance for all activities daily living. The MDS also revealed Resident #28 was continent of urine and bowel and had no skin issues. Review of the Preadmission Screening and Resident Review (PASARR) dated 09/26/17 revealed no schizophrenia diagnosis on the PASARR document. No updated PASARR was available. Interview with the Administrator on 08/25/22 at 1:00 P.M., verified the PASARR should have been updated when the new diagnosis was added. Page 1 of 9 365601 365601 08/29/2022 Alpine Nursing and Rehabilitation Center 164 Office Park Drive Xenia, OH 45385

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the Agency on Aging determinations, review of the hospital exemption form, and staff interview, the facility failed to complete the Preadmission Screening and Resident Review. This affected two residents (#19 and #42) out of three residents reviewed for Preadmission Screening and Resident Review. The census was 63. Residents Affected - Few Findings include: 1. Medical Record Review for Resident #42 revealed admission date of admission date of 07/27/12. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, aphasia, dysphagia, major depressive disorder, dementia, post polio syndrome, contracture, unspecified joint, psychosis not due to a substance or known physiological condition, and anxiety disorder. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident had impaired cognition. Review of the Agency on Aging dated 11/08/12 revealed Pre-admission Screening (PAS) Determination was not applicable. Level of Care Determination effective date 09/08/12, Intermediate Level of Care. There was no Preadmission Screening and Resident Review noted in the medical record. Interview on 08/23/22 at 3:35 P.M., the Administrator stated she was unable to locate documentation for Resident #42's Preadmission Screening and Resident Review. 2. Medical Record Review for Resident #19 revealed admission date of 03/24/22. Diagnoses included anxiety disorder, paranoid schizophrenia, diabetes mellitus type II, and unspecified convulsions. Review of the quarterly MDS dated [DATE] revealed the resident had severely impaired cognition. Review of the hospital exemption for preadmission screening ([NAME]) dated 03/24/22 revealed Resident #19 required fewer than 30 days of nursing facility services, no later than the date of discharge. Interview on 08/23/22 at 3:35 P.M., the Administrator stated she was unable to locate documentation for Resident #19's Preadmission Screening and Resident Review. 365601 Page 2 of 9 365601 08/29/2022 Alpine Nursing and Rehabilitation Center 164 Office Park Drive Xenia, OH 45385

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of the facility incidents, and policy review, the facility failed to ensure a fall investigation was completed and root cause was identified post resident fall. This affected one resident (#15) out of 20 sampled residents. The facility census was 63. Review of the medical record for Resident #15 revealed an admission date of 11/03/21. Diagnosis included obstructive and reflux uropathy, pseudobulbar affect, personal history of Covid-19, dementia, and adult failure to thrive. Review of the quarterly minimum data set (MDS) assessment dated on 06/23/22 revealed Resident #15 had severe cognitive impairment. Resident #15 required total dependence for bed mobility, dressing, bathing, and personal hygiene. Resident was setup assistance for all meals. Resident #15 required extensive one-person assistance for toilet use, and transfers. The resident used a wheelchair for ambulation. Review of the plan of care dated on 07/11/22 revealed Resident #15 was at risk for falls related to decreased mobility, medications, and memory impairment. Interventions included gripper socks when up, keep the bed in the lowest position except for care, keep the call light within reach, and therapy screening as needed. Review of the medical record for Resident #15 revealed there was a neurological check dated 07/03/22 at 7:00 P.M. through 07/04/22 at 6:00 A.M. Review of the medical record for Resident #15 revealed there was no fall investigation or Interdisciplinary team (IDT) meeting for follow up on the unwitnessed fall on 07/03/22. Review of the facility incidents dated from 02/28/22 through 08/23/22 revealed Resident #15 had an unwitnessed fall on 07/03/22. Interview on 08/24/22 at 4:20 P.M., with the Director of Nursing (DON) revealed the only thing she had for the fall for Resident #15 on 07/03/22 was the neurological check flow sheet. There was no fall investigation or root cause to why the resident fell on [DATE]. Review of the policy titled Fall Policy, review date 10/2018 revealed an investigation would be done on any incident where a resident, visitor, or staff member says a fall had occurred on a resident that was observed on the floor or resident was lowered to the floor with or without any injuries. 365601 Page 3 of 9 365601 08/29/2022 Alpine Nursing and Rehabilitation Center 164 Office Park Drive Xenia, OH 45385

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure weights were monitored per recommendation. This affected one resident (#42) out of seven residents reviewed for nutrition. The census was 63. Residents Affected - Few Findings include: Review of the medical record for Resident #42 revealed admission date of 07/27/12. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, aphasia, dysphagia, major depressive disorder, dementia, post polio syndrome, contracture, unspecified joint, psychosis not due to a substance or known physiological condition, and anxiety disorder. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #42 had impaired cognition. The resident required total assistance of two persons for bed mobility and transfers. The resident had a functional limitation in Range of Motion (ROM) on one side of the upper extremity and impairment on both sides of the lower extremities. The resident required supervision with setup help only for eating. The resident had no swallowing disorders and required a mechanically altered diet. Review of the care plan dated 07/24/22 revealed Resident #42 was at risk for altered nutrition and hydration status related to sedentary, unconcerned with weight status, cognitive impairments, dislikes white milk, need for mechanically altered diet due to dysphagia, no significant weight changes noted, variable oral intakes, supplements in place. On 08/22/22 a significant weight loss times 90 days was identified. Interventions included supplement change received, variable oral intakes. Interventions included honor food preferences/requests as able. Keep fluids available and within reach. Monitor and record meal percentage and fluid ounces at each meal. Monitor nutritional status and notify physician/dietician as indicated. Obtain/monitor weights as ordered. Provide supplement as ordered. Review of the dietary note dated 8/9/2022 at 5:04 P.M. revealed Resident #42 with weight loss noted and a re-weigh was requested to verify the weight loss. Nursing was notified and made aware. Review of the dietary note dated 8/22/2022 at 4:11 P.M. revealed Resident #42 had a weight change nutrition review: August weight: 140 pounds with significant weight loss of 11.8 pounds (7.8 percent) over 90 days. Non-significant weight loss of 13 pounds (8.5 percent) over 13 days. Current body mass index (BMI) 27.3 indicated overweight for height. Re-weigh was previously requested to verify weight loss and not noted currently. Question accuracy of August weight as previous weights had been stable and current oral intakes/supplement acceptance would not support current weight loss. Will add to weekly weights for monitoring. Continue with the plan and monitor weights, intake percentages, supplement acceptance and any changes. Review of the documented weights revealed no additional weights after 08/09/22. Interview on 08/25/22 at 9:35 A.M., the Administrator verified weights had not been completed as recommended. The Administrator stated the dietician notified the Assistant Director of Nursing (ADON) or the Director of Nursing (DON) of recommendations. She stated Resident #42 would be put on a list for the day to be weighed. She stated the charge nurse would be responsible to verify weights were completed and documented. The Administrator stated the recommendations were also discussed during 365601 Page 4 of 9 365601 08/29/2022 Alpine Nursing and Rehabilitation Center 164 Office Park Drive Xenia, OH 45385

F 0692 morning meetings. Level of Harm - Minimal harm or potential for actual harm Review of facility policy titled Weighing and Measuring the Resident, revised date 03/2011, revealed the purpose of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as as indicator of the nutritional status and medical condition of the resident, and to provide a baseline height in order to determine the ideal weight of the resident. Residents Affected - Few 365601 Page 5 of 9 365601 08/29/2022 Alpine Nursing and Rehabilitation Center 164 Office Park Drive Xenia, OH 45385

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #61's medical record revealed she was admitted to the facility on [DATE] with a diagnosis of bipolar disorder major depressive disorder, encounter for orthopedic aftercare, displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, vascular dementia with behavioral disturbance, type II diabetes, stage III kidney disease, and retention of urine. Resident #61 expired on [DATE] while at the facility. Review of the (MDS) assessment dated [DATE] revealed Resident #61 had severe cognitive impairment. Her functional status was listed as limited to one person assistance to totally dependent for all activities of daily living. The MDS also revealed Resident #61 was free of skin issues. Review of the care plan dated [DATE] revealed Resident #61 had a code status of full code. Review of the progress note dated [DATE] at 5:57 P.M. revealed Resident #61's family was called and explained her current condition. The family requested the resident be changed to Do Not Resuscitate Comfort Care (DNRCC) at this time and the physician was notified and made aware and the record updated. There was no other documentation about the change in resident condition. Review of the progress notes dated [DATE] at 9:30 P.M. revealed Resident #61 was found in her room without pulse, respirations, or a blood pressure at approximately 8:45 P.M. The absence of vitals was verified by two nurses. The Power of Attorney (POA) was notified at 9:00 P.M. and informed us to send the body to the local funeral home. The physician was notified at 9:07 P.M. and released the body to the funeral home. Interview with the Assistant Director of Nursing (ADON) #564 on [DATE] at 11:30 A.M., revealed she was unaware of the reason Resident #61 passed away or the details of her deterioration on [DATE]. The ADON confirmed the lack of documentation concerning the death of Resident #61 was inappropriate and unacceptable. Based on medical record review, staff and resident interview, and policy review, the facility failed to comprehensively document care provided for residents. This affected two residents (#54 and #61) of 24 resident record reviews. The census was 63. Findings include: 1. Medical Record Review for Resident #54 revealed admission date of [DATE]. Diagnoses included neoplasm of uncertain behavior of spinal cord, pressure ulcer unspecified site, stage III, pressure ulcer of sacral region, unspecified stage, and severe protein calorie malnutrition. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had intact cognition. The resident required extensive one person assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident required supervision set up help only for eating. The resident had a pressure ulcer/injury. The resident had one stage three pressure ulcer and two stage four pressure ulcers, one upon admission/entry or reentry. The resident received hospice care. 365601 Page 6 of 9 365601 08/29/2022 Alpine Nursing and Rehabilitation Center 164 Office Park Drive Xenia, OH 45385

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the plan of care dated [DATE] revealed the resident had actual skin impairment. Interventions included follow facility protocols for wound care. Review of the Treatment Administration Record (TAR) for [DATE] revealed documentation for sacral wound care, ordered twice daily, revealed no documentation on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] for the day shift. Documentation for monitoring the left knee and the left second toe until healed every shift was not documented on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] for the day shift. Documentation for output every shift was not completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] for the day shift. Interview on [DATE] at 11:30 A.M., Resident #54 stated he received wound care as ordered, some of his wounds had healed, and the wound physician provided all of his wound treatments every Thursday morning. Interview on [DATE] at 12:15 P.M., the Administrator verified the absent documentation on the TAR. Review of facility policy titled Charting and Documentation, revised date 07/2017, revealed all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 365601 Page 7 of 9 365601 08/29/2022 Alpine Nursing and Rehabilitation Center 164 Office Park Drive Xenia, OH 45385

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to ensure personal protective equipment was worn in resident areas to prevent the potential spread of infection. In addition, the facility failed to ensure contaminated linens and trash were handled to prevent the potential spread of infection. This had the potential to affect all 63 residents at the facility. Residents Affected - Many 1. Observation and interview on 08/22/22 at 8:52 A.M. State Tested Nurse Aide (STNA) #563 walked out of Resident #213 room. The STNA was wearing a N95 mask, eye protection, and an isolation gown. She walked down the walkway along the common area with no residents present and turned left out of view. The STNA returned within minutes carrying bath linens. The STNA #563 stated when she was given report at 6:00 A.M. she was told all residents on the corner were in isolation and believed she did not have to remove her gown if she was not entering another resident room or leave the isolated section of rooms. She then stated the Assistant Director of Nursing (ADON) #564 had just informed her that all the residents on that corner were no longer in quarantine/isolation. Observation of room [ROOM NUMBER] and #04 had personal protective equipment (PPE) carts with signage on the doors for droplet precautions. Rooms #05 and #07 had no signage and room [ROOM NUMBER] was open and appeared to be unoccupied. Interview on 08/24/22 at 4:45 P.M., with the ADON #564 said no gowns should be worn in the halls of the COVID unit. The ADON #564 stated the room was the quarantine area only. 2. Observation on 08/22/22 at 1:00 P.M. the Dietary Aid #529, who was also the Laundry Aid, was wearing a surgical mask on and was picking up dirty dishes from tables. There were three residents (#34, #57, and #47) in the dining room at this time who were not wearing any masks. Interview on 08/24/22 at 1:49 P.M., the Dietary Manager #567 stated the Dietary Aid #529 was educated about not wearing an N95 on around residents in the dining area on Monday 08/22/22 at 1:00 P.M. Dietary Manager #567 verified staff should wear an N95 mask around residents. 3. Observation and interview on 08/24/22 at 4:32 P.M. with STNA #651 who was carrying two bags around. One clear trash bag, and one light blue large trash bag. STNA #651 stated they were COVID-19 items and did not know where to dispose of them. Observation on 08/24/22 at 4:36 P.M. STNA #651 asked the nurse where to put the two bags that contained trash and dirty linen. The Registered Nurse (RN) #744 said to put the two bags back in the residents' room that he had taken it from. The RN #744 told STNA #651 to ask the aid on the next hall where to put the bags. STNA #651 put both clear trash bag and dirty linen bag back into room [ROOM NUMBER]. STNA #651 then went and asked STNA #823 where to put the bags and STNA #823 told STNA #651 to put both bags in the dirty linen room on the non-covid hall near the nurse's station. Observation on 08/24/22 at 4:38 P.M. STNA #651 went to the room [ROOM NUMBER] picked up the two bags and took the two bags to the dirty linen and trash room on the other hall. 4. Observation on 08/24/22 at 4:38 P.M. of the soiled linen and trash room near the nurse's station of the long term care hall, there was a soiled bath blanket and a soiled wash cloth laying on the floor not in a trash bag. 365601 Page 8 of 9 365601 08/29/2022 Alpine Nursing and Rehabilitation Center 164 Office Park Drive Xenia, OH 45385

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on 08/24/22 at 4:38 P.M., with STNA #823 verified the urine soiled bath blanket and wash cloth were laying on the floor and not in a receptacle or in a bag. Interview on 08/24/22 at 4:45 P.M., the ADON #564 said the the COVID-19 skilled unit had its own barrels to use for disposing of dirty linen or trash. ADON #564 said the STNA should not have brought the linen down to the other unit. Review of facility policy titled Coronavirus Prevention and Management that was revised on 08/08/2022, revealed when entering and exiting a COVID-19 positive unit, it was required to used Personal Protective Equipment that must be donned prior to entry of the unit and doffed prior to exiting the unit. Residents on isolation or quarantine will have droplet precautions, contact precautions, and how to don and doff Personal Protective Equipment (PPE). It is the policy of this facility to follow the frequently updated recommendations set forth by CMS, ODH, and CDC regarding the prevention and management of the COVID-19 virus. 365601 Page 9 of 9