Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0568
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing
home.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
staff interviews, review of facility policy, and record reviews, the facility failed to maintain full and complete
accounting records for the residents. This affected one (#45) of four resident reviewed for facility
management of funds. The facility identified 24 residents that the facility manages residents funds. The
facility census was 39.
Findings include:
Review of Resident #45's medical record revealed an admission date 05/09/16. Diagnoses included
schizoaffective disorder- bipolar type. Resident #45 has a court appointed guardian of person only. Review
of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #45 had cognitive
impairment with episodes of delusions and daily behavioral symptoms not directed at others.
Review of Resident #45's fund management service authorization and agreement to handle resident funds
signed by Resident #45's court appointed guardian on 03/24/23, stated that they authorized the facility to
establish and manage an Federal Deposit Insurance Corporation (FDIC) insured interest bearing resident
fund or burial account with options specified: Resident fund account- non-transferring account, (no
automatic transfer of deposits to pay for care cost) and direct deposit of social security.
Review of Resident #45's resident statement from 07/21/23 through 10/03/23 showed accounting detail of
withdraws and deposits into account. Review of receipts of cash withdraws found seven missing signatures
of receipt for Resident #45 on cash receipts on receipt number: 458758 for $40.00, 450766 for $52.00,
450770 for $28.51, 450779 for $4.99, 450795 for $40.00, 025802 for $100.00 and 025804 for $100.00.
Interview with Facility Staff #123 on 10/10/23 at 1:18 P.M. verified signatures of Resident #45 were missing
from multiple cash withdraw receipts for Resident #45 and that Resident #45 had 12 cash withdraw receipts
over $50.00 per day for the time period that was requested of 07/21/23 through 10/03/23.
Interview with the Administrator on 10/10/23 at 2:50 P.M. verified that per the facility policy, residents should
not receive more than $50.00 cash per day.
Review of the facility policy titled Resident Trust Policy and Procedure dated 05/27/20 stated, that no
individual other than the resident is authorized to sign for funds withdrawals, unless stated approval and
residents should not receive more than $50.00 cash per day, if more money is needed a
(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 7
Event ID:
365606
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
365606
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/10/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Als Woodstock Inc
1649 Park Rd
Woodstock, OH 43084
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 0568
check request should be submitted.
Level of Harm - Minimal harm
or potential for actual harm
This deficiency represents non-compliance investigated under Complaint Number OH00145834.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365606
If continuation sheet
Page 2 of 7
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
365606
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/10/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Als Woodstock Inc
1649 Park Rd
Woodstock, OH 43084
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 0711
Level of Harm - Potential for
minimal harm
Residents Affected - Many
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders,
at each required visit.
Based on record reviews, staff interviews, and review of the facility policy, the facility failed to provide signed
and dated current physician orders for the month of October 2023. This affected four (Residents #30, #42,
#45, and #47) of four residents reviewed for physician orders. This had the potential to affect all 39
residents residing in the facility that received physician services at the facility.
Findings include:
Review of Resident #30, #42, #45, and #47's paper and electronic medical records revealed there were no
October 2023 signed physician orders summary.
Interview on 10/05/23 at 11:05 A.M. with the Director of Nursing (DON) stated the house physician took the
paper monthly physician orders summary for October, for every resident, with him when he was here
Wednesday, (10/04/23) and returns them on his next scheduled visit. The DON stated that no copies of the
orders were available in the charts or electronically until he returned with them, and this was a common
practice of the physician, and it was done each month.
Review of the facility policy titled Medication Orders, dated 07/01/21, revealed medication orders are
recapped monthly when the prescriber signs the physician order summary. A designated nurse reviews the
order summary before giving it to the prescriber to sign. Further stating, applicable formularies, protocols or
prescribing guidelines are kept on file in the facility and are followed closely.
This was an incidental finding discovered during the complaint investigation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365606
If continuation sheet
Page 3 of 7
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
365606
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/10/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Als Woodstock Inc
1649 Park Rd
Woodstock, OH 43084
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 0808
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or
licensed dietitian, to the extent allowed by State law.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
resident and staff interviews and record reviews, the facility failed to provide residents a diet order to meet
their daily nutritional needs. This affected two (Residents #30 and #45) of four residents reviewed for
therapeutic diets. The facility census was 39.
Findings include:
1. Review of the medical record for Resident #30 revealed an admission date of 08/15/2023 with diagnoses
of acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and emphysema.
Review of the admission Minimum Data Set (MDS) 3.0 assessment indicated Resident #30 had no
cognitive impairment. Resident #30 had verbal behavioral symptoms which occurred one to three days
during the assessment period and had no rejection of care. Resident #30 was independent with eating.
Review of Resident #30's physicians orders revealed they were silent for a diet order.
Interview on 10/05/23 at 10:28 A.M., with Resident #30 stated he should be receiving a diet that was
consistent with his diagnosis, that did not contain any salt. Resident #30 also stated the food portion sizes
were also wrong.
Interview with Director of Nursing, (DON) on 10/10/23 at 12:20 P.M. confirmed Resident #30 had no
physician order for a diet.
2. Review of Resident #45's medical record revealed an admission date of 05/09/16. Diagnoses not
included schizoaffective disorder- bipolar type, chronic obstructive pulmonary disease, and hypertension.
Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #45 had
cognitive impairment with episodes of delusions and daily behavioral symptoms not directed at others.
Resident #45 was independent with eating.
Review of Resident #45's physician order dated 07/13/22 revealed an order for 1,400 milliliter (ml) fluid
restrictions daily as follows: dietary would provide 360 ml three times a day with each meal and nursing to
administer eight ml four times a day with medications.
Interview on 10/10/23 at 12:40 P.M. with Dietary Staff #106 verified Resident #45 had not been receiving
the correct amount of fluid that was allotted to dietary that he was receiving 480 ml total for breakfast and
lunch and 360 ml for dinner.
Interview and record review with LPN #120 on 10/10/23 at 12:48 P.M., revealed Resident #45's medication
administration record (MAR) and the physician order dated 07/13/22 verified nursing was to administer
eight ml with medication pass four times a day. LPN #120 stated that nursing had been providing more than
eight ml of fluid four times a day with medication pass. LPN #120 stated she provided a cup which was 120
ml to 180 ml and proceeded to remove a plastic cup from the medication cart indicating the cup used.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365606
If continuation sheet
Page 4 of 7
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
365606
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/10/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Als Woodstock Inc
1649 Park Rd
Woodstock, OH 43084
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 0808
Level of Harm - Minimal harm
or potential for actual harm
Interview with Director of Nursing, (DON) on 10/10/23 at 12:55 P.M. confirmed Resident #45's physician
order dated 07/13/22 stated for nursing to administer eight ml four times a day with medications. The DON
verified this was a transcription error on the order since 07/13/22.
This deficiency represents non-compliance investigated under Complaint Number OH00145834.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365606
If continuation sheet
Page 5 of 7
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
365606
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/10/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Als Woodstock Inc
1649 Park Rd
Woodstock, OH 43084
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 0826
Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor.
Level of Harm - Minimal harm
or potential for actual harm
Based on resident and staff interviews, review of facility policy, and record reviews, the facility failed to
provide a written physicians order for specialized rehabilitative services for a resident. This affected one
(Resident #30) of four residents reviewed for specialized rehabilitative services. The facility census was 39.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #30 revealed an admission date of 08/15/23. Diagnoses included
acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and emphysema. Review of
the admission Minimum Data Set (MDS) 3.0 assessment, dated 08/22/23 revealed Resident #30 had no
cognitive impairment.
Review of Resident #30's physician orders for 08/15/23 to 09/15/23 revealed there were no physician
orders for specialized rehabilitative services for Resident #30.
Records of the therapy service records revealed their records were kept in a separate electronic medical
record system for therapy. Review of Resident #30's service log summary of physical therapy revealed a
60-minute evaluation was provided 08/22/23. In August and September 2023, Resident #30's attendance,
and treatment for muscle weakness were for a total of 244 minutes on: 08/23/23, 08/24/23 08/29/23,
09/05/23, 09/06/23, 09/07/23, 09/13/23, and 09/14/23.
Interview on 10/05/23 at 10:28 A.M. with Resident #30 stated he was not receiving therapy anymore and
not sure why.
Interview on 10/10/23 at 9:18 A.M. with Therapy Staff #105 verified Resident #30 received physical therapy
services August and September of 2023 for strengthening and services was stopped when Resident #30
had a hospital stay. Therapy Staff #105 verified there was no documentation of services ending for Resident
#30.
Interview with Director of Nursing (DON) on 10/10/23 at 12:20 P.M. confirmed Resident #30 had no
physician order for specialized rehabilitative services that had been provided in August and September
2023.
Review of the facility's undated policy titled admission Agreement revealed all services provided by the
facility will be in accordance with the general and specific instruction and/or orders of the resident's
attending physician. The resident hereby consents and agrees to the facility rendering nursing care and
other treatment (including without limitation, rehabilitation therapy and other ancillary services provided) in
accordance with the attending physician's instructions and or orders.
This deficiency represents non-compliance investigated under Complaint Number OH00145834.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365606
If continuation sheet
Page 6 of 7
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
365606
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/10/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Als Woodstock Inc
1649 Park Rd
Woodstock, OH 43084
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 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
Based on observations, resident and staff interviews, and review of the facility policy, the facility failed to
provide a clean and sanitary environment for the residents. This affected Resident #36 and #43 and had the
potential to affect all 39 residents who resided in the facility.
Findings include:
Observation on 10/05/23 from 8:30 A.M. through 11:30 A.M. revealed there were four halls where residents
resided and traveled throughout the facility. All the halls in the facility were carpeted. The carpeting in all
halls was embedded with black dirt, grime, food, and fluid spills. The carpeting was soiled from the
beginning of each carpeted area through the end. Many areas on each hall had large, discolored areas with
stained like areas. In the dining area, there was visible food residue under the tables and throughout the
floor. On the walls in the dining area and in the four resident hallways, there were visible cobwebs
containing insects in multiple corners and, on the keypads, leading to the outside of the facility were a large
number of dead insects on top of the keypads. Throughout the facility, hall and dining light panels contained
visual evidence of accumulation of clumps of dirt or insect residue inside the lighting.
Inside each of the residents' rooms was flooring that had visible grime or dirt. Resident #43's room and
Resident #36's room had sticky residue that stuck to shoes and caused a sticking sound when entering the
resident's rooms.
When entering Resident #43's room on 10/05/23 at 9:05 A.M, an audible sticking sound occurred when
walking into the room. Interview with Resident #43 stated, the floors are always dirty, while making hand
motions towards the visible grime on the flooring.
Interview on 10/05/23 at 10:13 A.M. with Resident #36 stated that her room floors were dirty, visible dark
staining and food residue was on floor surrounding reclining chair and near bed.
Interview and subsequent observations on 10/10/23 at 9:23 A.M. with Housekeeper #102, stated the facility
did not have a commercial carpet cleaner and it was needed to clean the carpets. Housekeeper #102
stated the floors in the residents' rooms had not been waxed in six to seven months causing the stickiness
and grime type build up on the residents' floors. Housekeeper #102 verified the food remnants in the dining
area and further acknowledging the visible accumulation of clumps of dirt or insect residue contained inside
the lights in the dining room.
Interview and subsequent observations with the Administrator on 10/05/23 at 9:45 A.M. verified the dead
insects on top of the keypad leading to the outside in the resident hallways and the visible cobwebs in the
corner of the hallways.
Review of the facility's undated policy titled Daily Cleaning Check List revealed a daily schedule cleaning of
resident room requirements of swept and moped of room, wipe down walls if needed check all lights are
dusted and working and no cobwebs or standing dust.
This deficiency represents non-compliance investigated under Complaint Number OH00145834.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365606
If continuation sheet
Page 7 of 7
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F568 - Accounting and Records
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
F711 - Physician Visits
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
F808 - Therapeutic Diets
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
F826 - Qualifications
Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
FAQ · About this visit
Common questions about this visit
What happened during the October 10, 2023 survey of ALS WOODSTOCK INC?
This was a inspection survey of ALS WOODSTOCK INC on October 10, 2023. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ALS WOODSTOCK INC on October 10, 2023?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.