Inspection·February 29, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 interviews, and policy review, the facility failed to complete an assessment and implement a treatment for a newly developed pressure ulcer. This affected one (#43) out of three residents reviewed for pressure ulcers. The facility census was 65. Residents Affected - Few Findings included: Review of the medical record Resident #43 revealed an admission date of 09/01/16 with medical diagnoses of chronic obstructive pulmonary disease, chronic respiratory failure, peripheral vascular disease, and hypertension. Review of the medical record for Resident #43 revealed an annual Minimum Data Set (MDS), dated [DATE], which indicated Resident #43 was cognitively intact and required substantial/maximum staff assistance for bed mobility, bathing, transfers, and toileting. The MDS indicated Resident #43 was always incontinence of bladder and frequently incontinent of bowel. The MDS indicated Resident #43 did not have any pressure ulcers. Review of the medical record for Resident #43 revealed a nurse's note dated 02/15/24 at 5:50 P.M., written by Registered Nurse (RN) #217 which stated the nurse observed small pressure sore to the residents buttocks. The note continued to state the State Tested Nursing Assistant (STNA) informed her the area was present last week but had opened since then. The note stated the area was cleaned, ointment was applied, and the Assistance Director of Nursing (ADON) was notified. Further review of the medical record revealed a nurse's note, dated 02/16/24 at 11:40 A.M. which stated the nurse assessed the open area to resident's sacrum which measured 1.1 centimeters (cm) by 1.4 cm by 0.1 cm. The note stated the wound bed was dark red in the center and pink toward the outer edges and no drainage or odor was noted. The note continued to state the Physician Assistant, the wound Nurse Practitioner (NP), resident's power of attorney, and the dietician were notified. Review of the medical record for Resident #43 revealed a physician order dated 02/16/24 to cleanse sacrum with wound cleanser, pat dry, apply medi-honey to wound bed, cover with bordered gauze and to change daily and as needed. The medical record did not contain documentation to support a treatment to the sacrum was ordered prior to 02/16/24. Review of the medical record for Resident #43 revealed weekly skin assessments dated 02/05/24 and 02/12/24 which stated Resident #43 had no skin issues. The weekly skin assessment dated [DATE] stated Resident #43 had a small pressure sore to buttocks. Further review of the medical record revealed a pressure skin grid assessment dated [DATE] which stated Resident #43 was noted to have a Stage II pressure ulcer to the sacrum area on 02/15/24. The wound measured 1.1 cm by 1.4 cm by 0.1 cm. The (continued on next page) 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 02/29/2024 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)