F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observation and resident and staff interviews, the facility failed to ensure residents were
treated with dignity by ensuring the residents indwelling (Foley) urinary catheter collection bag was
covered. This affected one (#11) of three residents reviewed for indwelling (Foley) urinary catheters. The
facility census was 71.
Findings include:
Review of medical record for Resident #11 revealed admission date of. 10/31/22. Diagnoses included
depression, schizophrenia, Crohn's disease and ulcerative colitis.
The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #11 had Brief Interview Mental
Status (BIMS) score of 15 out of 15 indicating intact cognition. Resident #11 required extensive two person
transfers, toileting, one person assistance for bed mobility and supervision for eating. Resident #11 had an
indwelling (Foley) urinary catheter.
Observation and interview on 06/07/23 at 10:14 A. M with Resident #11 revealed he was sitting just inside
the doorway to his room with the collection bag for his indwelling (Foley) urinary catheter hooked to his
wheelchair. Resident #11's collection bag was observed to be uncovered and contain approximately 100
milliliters of urine. Resident #11 verified he would like the indwelling (Foley) urinary catheter it to be
covered.
Interview on 06/07/23 at 10:14 A.M. with Physical Therapy Assistant (PTA) #13 verified the collection bag
for Resident #11's indwelling (Foley) urinary catheter bag was uncovered.
Interview on 06/07/23 at 9:47 A.M. with State Tested Nursing Assistant #12 and on 06/08/23 at 10:52 A.M.
with STNA #22 revealed they were unaware the facility had covers for residents indwelling (Foley) urinary
catheter collection bags. STNA #12 and #22 both stated they sometimes use a pillowcase.
This deficiency represents non-compliance investigated under Complaint Number OH00143060.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
365601
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
06/13/2023
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observation and resident and staff interviews, the facility failed to ensure a resident's privacy
curtain was clean and/or free of stains. This affected one (#78) of three residents reviewed for the physical
environment. The facility census was 71.
Findings include:
Review of medical record for Resident #78 revealed admission date of 07/06/20. Diagnoses included
paraplegia, neuromuscular dysfunction of bladder, hepatitis C, contracture of left lower leg, anxiety,
depression and insomnia.
The five-day Minimum Data Set (MDS) dated [DATE] revealed Resident #78's Brief Interview Mental Status
(BIMS) score of 15 indicating intact cognition. Resident #78 was independent for bed mobility, transfers,
eating and total dependence for toileting.
Observation and interview on 06/07/23 at 9:02 A.M. revealed Resident #78's privacy curtain had a dark,
brown stain towards the head of the bed and was approximately 12 inches by (x) eight inches at bed level.
Resident #78 revealed he was unsure what was on the curtain and stated it may be barbecue sauce, but he
did not know if the curtain had been cleaned since he had been there. Resident #78 stated he would like to
have it cleaned.
Interview on 06/07/23 at 9:14 A.M. with Housekeeper #10 revealed she cleans rooms daily including
Resident #78's room. Housekeeper #10 verified there was an unsightly stain on the privacy curtain in
Resident #78's room and stated she was unsure the last time it had been cleaned.
This deficiency represents non-compliance investigated under Complaint Number OH00143060.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365601
If continuation sheet
Page 2 of 2
