Inspection·November 12, 2024

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 record review, observation, interviews, and policy / procedures the facility failed to perform incontinence care in a sanitary manner. This affected one (#19) out of three residents reviewed for incontinence care. The facility census was 67. Residents Affected - Few Findings include: Review of the medical record for Resident #19 revealed an admission date of 04/11/28 with diagnoses of cerebral infarction due to unspecified occlusion or stenosis of unspecified carotid artery, hypertensive heart disease with heart failure, and obesity. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate cognitive impairment. Resident #19 required setup assistance with eating, substantial assistance with personal hygiene, and was dependent on staff assistance with oral hygiene, toileting hygiene, bathing, dressing, bed mobility. Review of the care plan dated 06/24/22 revealed Resident #19 had bladder and bowel incontinence, with interventions to assist resident to the bathroom as needed and to provide peri care after each incontinence episode. Review of the Auarterly Bowel & Bladder Assessment completed on 10/09/24 revealed resident was incontinent of bladder and bowel. Observation on 11/07/24 at 8:38 A.M. with Certified Nursing Assistant (CNA) #130 and CNA #790 performing incontinence care on Resident #19 revealed the CNA's entered the resident's room, washed their hands, prepared a water basin with wet washcloths, soap, and dry washcloths. CNA #130 and CNA #790 explained the procedure to Resident #19. CNA #130 and CNA #790 washed their hands, applied clean clothes and approached Resident #19. Resident #19's attend was opened in the front and rolled down between her legs. CNA #790 used a clean washcloth with soap to wash Resident #19's right peri-fold, left peri-fold outer labia, and the inner-labia with a clean section of the washcloth with each stroke. CNA #790 used a clean washcloth to rinse Resident #19's right peri-fold, left peri-fold outer labia, and the inner-labia with a clean section of the washcloth with each stroke. CNA #790 used a dry washcloth to dry Resident #19's peri-area. CNA #790 changed her gloves. Resident #19 was positioned onto her right side. CNA #790 used a clean washcloth with soap to wash Resident #19's buttocks/sacrum area. CNA #790 used a clean washcloth to rinse Resident #19's buttocks/sacrum area. CNA #790 used a dry washcloth to dry Resident #19's buttocks/sacrum area. A clean attends was applied, Resident #19 was repositioned in bed, her call light was handed to her, and her oxygen tubing was picked up by the nasal cannula area and handed to her by CNA #790. CNA #130 and CNA #790 removed their gloves and washed their hands prior to exiting the room. Interview on 11/07/24 at 8:48 A.M. with CNA #790 confirmed during incontinence care on Resident #19 she did not change her gloves after performing incontinence care to the resident's buttocks/sacrum area. Interview also confirmed the resident was repositioned, the blankets were placed on the resident, the call light was handed to the resident, and the oxygen tubing was picked up by the nasal cannula area all while continuing to wear the same gloves she used while performing incontinence care. Interview also confirmed she should have removed her soiled gloves and washed her hands prior to covering the resident up, prior to repositioning the resident, prior to handing the call light to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365601 If continuation sheet Page 2 of 3 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 11/12/2024 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)

F 0880 resident, and prior to picking up the nasal cannula for oxygen and handing it to Resident #19. Level of Harm - Minimal harm or potential for actual harm Interview on 11/07/24 at 8:56 A.M. with CNA #130 confirmed while performing incontinence care with CNA #790 they did not change their gloves after incontinence care was complete. Interview also confirmed they should have removed their soiled gloves and washed their hands prior to covering the resident up, prior to repositioning the resident, prior to handing the call light to the resident, and prior to picking up the nasal cannula for oxygen and handing it to Resident #19. Residents Affected - Few Review of the Incontinence Management Standard of Care policy, undated revealed It is the policy of this facility to promote intact skin, maintain dryness and respect the resident's standard and individualized interventions. Review of the Perineal Care procedure, undated revealed the procedure of for providing perineal care is Washes hands, applies disposable gloves, explains procedure to resident. And Cleanse skin folds thoroughly, rinses, and pats dry. And Removes and appropriately discards soiled gloves. Repositions and covers patient. Places call light in reach. This deficiency represents non-compliance investigated under Complaint Number OH00159419. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365601 If continuation sheet Page 3 of 3