Health inspection·December 27, 2023

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview with staff and residents, and review of daily menus, the facility failed to follow menus plan to provide nutritious and well-balanced meals. This had the potential to affect all 39 residents who the facility identified as receiving food from the kitchen. The facility census was 39. Findings include: Observation on 12/26/23 at 11:48 A.M. of test tray revealed sloppy joe sandwich, mixed vegetables, and cantaloupe served. The food was palatable. The menu revealed lunch was to be a hamburger, French fries, tossed salad, and cantaloupe. Review of medical record for Resident #03 revealed an admission date of 02/19/18 with diagnoses including but not limited to cerebral palsy, chronic obstructive pulmonary disease, dysphagia, anxiety, type two diabetes, epilepsy, borderline personality disorder, and major depression. Review of Minimum Data Set (MDS) dated [DATE] revealed Resident #03 was cognitively intact and required limited assistance for personal hygiene and transfers. Review of monthly weights for Resident #03 revealed no significant weight loss. Review of medical record for Resident #06 revealed admission date of 08/31/20 with diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarctions affecting non-dominant left side, non-traumatic subarachnoid hemorrhage, bipolar disorder, hypertension, and impulsiveness. Review of MDS dated [DATE] revealed Resident #06 was cognitively intact and required maximal assistance for personal hygiene, showers, and transfers. Resident required set up assistance with meals. Review of monthly weights for Resident #06 revealed no significant weight loss. Review of the daily printed menus revealed Thursday 12/07/23 for dinner, residents received breaded fish sandwich, coleslaw, and banana pudding. Saturday 12/09/23 for lunch received turkey goulash, mixed vegetables, and cantaloupe. Tuesday 12/12/23 for dinner received baked fish, [NAME] slaw, dinner roll, and vanilla pudding. Wednesday 12/13/23 for lunch received cheese pizza, side salad, and cookies. Thursday 12/14/23 for lunch received polish sausage on a bun, sauerkraut, and apple slices and for dinner received pork roast, peas, dinner roll, and cookies. Friday 12/15/23 for lunch received sloppy joe sandwich, corn on the cob, and banana. Saturday 12/16/23 for lunch received macaroni and cheese, stewed tomatoes, and cookies. Sunday 12/17/23 for dinner received baked ham, peas, biscuits, and banana pudding. Monday 12/18/23 for lunch received sloppy joe sandwich, corn, and cantaloupe. Wednesday 12/20/23 for dinner received veal patty, Italian blend vegetables, dinner roll, and banana pudding. Review of Gordon's simple menu plan utilized by facility revealed menu should have been Thursday 12/07/23 for dinner breaded fish sandwich, potato wedges, beets, plain muffin, and choice of pudding. Saturday 12/09/23 lunch turkey goulash, green beans, tossed salad, wheat bread, and cantaloupe. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365606 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 365606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Wednesday 12/13/23 lunch cheese pizza, Italian green beans, and banana. Thursday 12/14/23 lunch polish sausage, French fries, cooked cabbage, apple slices and dinner tropical pork, white rice, oriental vegetables, choice of roll, and choice of cookie. Friday 12/15/23 lunch tomato Florentine, saltines, ground turkey, green peas, and cantaloupe. Saturday 12/16/23 lunch sloppy joe and macaroni and cheese, key west vegetables, cornbread, and banana. Sunday 12/17/23 dinner baked glazed ham, au gratin potatoes, carrots, and southern style biscuits. Monday 12/18/23 lunch sloppy joe, corn on the cob, choice of roll, and cantaloupe. Wednesday 12/20/23 dinner veal piccata, egg noodles, Italian blend vegetables, choice of roll, and choice of pudding. Interview on 12/27/23 at 8:43 A.M. with Dietary Manager (DM) #153 verified their menus comes from Gordon's and they are using the fall/winter simple menu from 2023. Interview on 12/27/23 at 9:08 A.M. with DM #153 verified he was not always following the menu due to some staff not knowing how to cook some of the items so they will substitute. DM #153 stated there is not money enough in the budget to order what he needs. DM #153 verified he sometimes had to substitute foods due to not having what he needed to do the correct menus. DM #153 stated he thought that a roll or bread would be sufficient enough to substitute for the starch in the meal such as French fries, noodles, rice, and/or potatoes. Interview on 12/27/23 at 1:42 P.M. with Resident #06 stated that on Christmas day the residents received a bologna sandwich and potato wedges. Resident #06 stated on 11/24/23 she got three meatballs and a dinner roll for supper and one day she received ham and a roll with no vegetable. Resident #06 stated they do not always get what feels like a full meal that is nutritious. Interview on 12/27/23 at 1:23 P.M. with Resident #10 stated she does not feel she gets enough food for meals. The resident stated that some days the food is good, and others are not good. The resident stated one day they received Swedish meatballs and vegetable but no rice or noodles. This deficiency represents non-compliance investigated under Complaint Numbers OH00149450 and OH00148830. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365606 If continuation sheet Page 3 of 3