Health inspection·January 25, 2024

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on resident and staff interviews, and record review, the facility failed to ensure resident concerns brought up at the resident council meeting were addressed timely and appropriately. This affected nine (#05, #07, #10, #13, #14, #18, #30, #32, and #36) residents in regular attendance of the resident council meetings. The Facility census was 39. Residents Affected - Some Findings include: Review of the resident council meeting minutes dated 09/2023 revealed concerns related to the Administrator, needing to spend more time in the facility and concerns related to nursing and the staff taking too long to answer call lights. Review of the resident council meeting minutes dated 12/2023 revealed concerns related to the Administrator, messing things up, making promises that were not kept, and he couldn't remember what he was told. The meeting also brought up concerns related to agency nurses. Interview on 01/22/24 at 11:00 A.M. with Resident #23 revealed the facility does not address resident concerns timely and revealed the Administrator was not seen often at the building fixing the concerns. Interview on 01/22/24 at 12:05 P.M. with Activities Director #220 revealed she typically would submit the concern forms that were brought up in the resident council meetings. Activities Director #220 revealed the concern forms were not completed for the nursing concerns or the administration concerns as the facility had no procedure in place for those type of concerns. Activity Director #220 revealed the facility had no evidence of acknowledging or addressing the resident concerns and revealed the facility had no follow- up regarding the concerns for nursing call lights and agency staffing as well as for the administration concerns. Interview on 01/23/24 at 12:00 P.M. with Corporate Administrator #250 and Corporate Nurse #260 confirmed there was no documented evidence of any follow-up related to resident concerns related to the staffing or the administration concerns. Corporate Administrator #250 could not provide the requested call light audits for review. Review of the facility policy titled Resident Council, dated 01/2014, revealed Resident Council meetings would be held monthly and as needed and all concerns would be documented on a Resident concern form and forwarded to the Administrator for appropriate follow up. The concern or grievance form that should be returned should be addressed by the appropriate department and document the outcome of the concern review and return documentation evidence to Activity Director. Page 1 of 10 365606 365606 01/25/2024 Als Woodstock Inc 1649 Park Rd Woodstock, OH 43084

F 0565 This deficiency represents non-compliance investigated under Complaint Number OH00149489. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 365606 Page 2 of 10 365606 01/25/2024 Als Woodstock Inc 1649 Park Rd Woodstock, OH 43084

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview and record review, the facility failed to ensure resident's representatives were notified when a change in condition occurred. This affected two (#16 and #21) of three residents reviewed for change in condition. The facility census was 39. Findings include: 1. Review of the medical record for the Resident #16 revealed an admission date of 06/24/16. Diagnoses included hemiplegia and hemiparesis unspecified cerebrovascular disease, bipolar disorder, dysphasia, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively impaired with a Brief Interview Mental Status (BIMS) of six and required moderate assistance from staff with eating. Resident #16 was dependent on staff for mobility and transfers. Review a nurse's progress note dated 11/24/23 for Resident #16 revealed the nurse noticed a change in condition when the resident had an altered mental status, had dark foul-smelling urine and the physician was contacted to obtain laboratory (lab) tests. The note revealed no documented evidence of the resident's representative being notified. Additionally, a nurse's progress note dated 12/27/23 revealed the resident was placed in Coronavirus (COVID-19) quarantine/isolation due to exposure, and there was no documentation of the resident's representative being notified. 2. Review of the medical record for the Resident #21 revealed an admission date of 12/28/17. Diagnoses included Huntington's disease, repeated falls, dysphasia, muscle weakness, delusions disorder, dementia with behavioral disturbance and major depression. Review of a nurse's progress note dated 11/10/23 revealed Resident #21 had a fall from the bed onto the ground. There was a fall mat in place, but it appeared that the resident had fallen off the mat as well and the mat slipped from its assigned spot. Resident #21 was noted to have abrasions noted to the right forehead and right elbow and a bruising to right cheekbone and knee. Resident #21 reported he was fine and neurological (neuro) checks were initiated. The progress notes revealed no documented evidence the resident's representative was notified concerning the fall with injuries on 11/10/23. Additionally, a nurse's progress note dated 12/27/23 revealed the resident was placed in quarantine/isolation due to COVID-19 exposure and there was no documented evidence of the resident's representative being notified. Review of fall report form dated 11/10/23 for Resident #21 revealed a staff member's statement of the fall; however, the statement did not include any documented evidence of the resident's representative being notified of the fall. Review of the MDS assessment dated [DATE] revealed Resident #21 was cognitively impaired and was dependent on staff for all activities of daily living (ADLS) tasks and mobility including eating. Interview on 01/23/24 at 11:50 A.M. with Corporate Nurse #260 confirmed the facility had no documented evidence of Resident #16 and Resident #21's representatives being notified after they had changes in condition including a fall with injury, changes in their medical symptoms and when the 365606 Page 3 of 10 365606 01/25/2024 Als Woodstock Inc 1649 Park Rd Woodstock, OH 43084

F 0580 residents were placed in COVID-19 quarantine/isolation. Level of Harm - Minimal harm or potential for actual harm Review of facility policy titled Change in a Resident ' s Condition, dated 08/2023, revealed the facility shall notify the resident, attending and resident representative of changes in condition. Unless otherwise instructed by the resident, the nurse supervisor will notify the resident ' s family or representative. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00149489. 365606 Page 4 of 10 365606 01/25/2024 Als Woodstock Inc 1649 Park Rd Woodstock, OH 43084

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 observation, resident and interviews, and record review, the facility failed to maintain a home like environment for one (#16) of three residents reviewed for physical environment. The facility census was 39. Findings include: Review of the medical record for the Resident #16 revealed an admission date of 06/24/16. Diagnoses included hemiplegia and hemiparesis unspecified cerebrovascular disease, bipolar disorder, dysphasia, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively impaired with a Brief Interview Mental Status (BIMS) of six and was dependent on staff for activities of daily living (ADLS). Interview and observation on 01/22/24 at 12:15 P.M. with Resident #16 revealed an outlet cover above him was hanging out of the wall approximately eight inches and had a cable cord hanging from it. The resident reported it had been that way since he was moved to the room a few weeks ago. Interview on 01/22/24 at 12:34 P.M. with State Tested Nursing Aide #212 confirmed Resident #16 had a cable outlet cover hanging out of the wall about eight inches and hanging above the bed. The cable cord was still screwed into the outlet cover and was a safety hazard. Review of facility policy titled Resident Environment Quality, undated, revealed facility shall maintain resident rooms including mechanical electrical and patient care equipment in safe working order. 365606 Page 5 of 10 365606 01/25/2024 Als Woodstock Inc 1649 Park Rd Woodstock, OH 43084

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, staff interviews and record review, the facility failed to ensure dependent residents received showers as scheduled. This affected two (#16 and #21) of three residents reviewed for activities of daily living (ADLs). The Facility census was 39. Residents Affected - Few Findings include: 1. Review of the medical record for the Resident #16 revealed an admission date of 06/24/16. Diagnoses included hemiplegia and hemiparesis unspecified cerebrovascular disease, bipolar disorder, dysphasia, and muscle weakness. Review of the shower preference document revealed Resident #16 was scheduled to get showers on Sundays and Wednesdays. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively impaired with a Brief Interview Mental Status (BIMS) of six and the resident was dependent on staff for bathing. Review of the shower sheets from the past three months (10/15/23 to 01/23/24) for Resident #16, revealed the resident was offered showers on (Sunday) 10/15/23, (Sunday) 10/29/23, (Monday) 11/06/23, (Wednesday) 11/08/23, (Sunday) 11/12/23, (Sunday) 11/19/23, (Wednesday) 12/06/23, (Wednesday) 12/13/23, (Tuesday) 12/19/23, (Sunday) 01/07/24, (Wednesday) 01/10/24 and (Saturday) 01/20/24. Documents indicated the resident missed 16 shower opportunities. A shower sheet dated 12/31/23 was blank except for a comment saying COVID positive. Interview on 01/22/24 at 12:15 P.M. with Resident #16 revealed he had only had one shower in the last two weeks. The resident revealed he had trouble getting staff to help him with showers. 2. Review of the medical record for the Resident #23 revealed an admission date of 02/19/18. Diagnoses included cerebral palsy, diabetes, somatization disorder, epilepsy, borderline personality disorder, dysphasia, paraplegia, and muscle weakness. Review of the shower preference document revealed Resident #23 was scheduled to get showers on Mondays and Thursdays Review of the MDS assessment dated [DATE] revealed Resident #23 was cognitively intact with a BIMS of 15 and required maximum assistance with bathing. Review of the shower sheets from the past three months (10/23/23 to 01/23/24) for Resident #23 revealed no documented evidence of any showers from 10/23/23 to 12/04/23. Resident was offered showers on (Monday) 12/04/23, (Monday) 12/12/23, (Wednesday) 12/14/23, (Friday) 12/22/23, (Monday)12/25/23, (Thursday) 12/28/23, (Monday) and (Tuesday) 01/23/24 with only one refusal on 01/22/23 due to the resident complaining of pain. The resident missed 20 shower opportunities in the three months reviewed. Review of a nurse's progress note dated 11/21/23 for Resident #23 revealed the resident takes 60-90 minutes to shower and then another 20-30 minutes after shower for care and was monopolizing the staffs' time. No other notes mentioned showers from 10/01/23 to 01/23/24. Review a nurse's progress note dated 01/23/24 for Resident #23 revealed the resident declined a shower due to pain from a urinary tract infection (UTI) and currently on antibiotics. 365606 Page 6 of 10 365606 01/25/2024 Als Woodstock Inc 1649 Park Rd Woodstock, OH 43084

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 01/22/24 at 11:00 A.M. with Resident #23 revealed he should be scheduled for showers on Mondays and Thursday and his preference was to have a shower twice weekly; however, the facility had been using a lot of agency staffing over the last several weeks and reported he had not been offered showers as scheduled. The resident reported he would go weeks without staff offering a shower and when he asked for one, he was told it was not his day for a shower, the staff didn't have time and /or it was not the staff member's job. Observation at the same time revealed the resident had some shaggy, unkempt facial hair and his hair was pulled back into a braid and appeared to be slick and greasy. Interview on 01/23/24 at 11:24 A.M. with Director of Nursing (DON) confirmed Residents #16 and #23 had missed bathing/showers. The DON reported she was not sure why the residents were missing bathing/showers as the facility had enough staffing to complete those tasks. The DON indicated the shower sheets provided to the Surveyor for Residents #16 and #23 were all the facility had. Interview on 01/23/24 at 11:40 A.M. with State Tested Nursing Aides (STNA) #208 and #212 revealed they are aware of residents not getting bathing/showers as scheduled. STNAs #208 and #212 indicated residents complained that agency aides were not providing showers as requested and as scheduled. STNAs #208 and #212 reported they were instructed by management that residents who were in isolation/quarantine for COVID, were not to receive bathing/showers as scheduled so they would mark COVID on the resident's shower sheets. Review of facility policy titled Bathing Policy, dated 08/2022, revealed residents had the option to take a bath or shower as often as they would like and choose the time of day to have it completed. 365606 Page 7 of 10 365606 01/25/2024 Als Woodstock Inc 1649 Park Rd Woodstock, OH 43084

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and record review, the facility failed to ensure resident's call lights were answered timely. This affected one (#23) of the three residents reviewed for call lights. The facility census was 39. Residents Affected - Few Findings include: Review of the medical record for the Resident #23 revealed an admission date of 02/19/18. Diagnoses included cerebral palsy, diabetes, somatization disorder, epilepsy, borderline personality disorder, dysphasia, paraplegia, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact with a Brief Interview Mental Status (BIMS) of 15 and required partial assistance from staff for mobility and activities of daily living (ADLs). Interview on 01/22/24 at 11:00 A.M. with Resident #23 revealed the facility did not have enough staff to provide needed care for residents and had long waits for the call lights to be answered. Observation at the same time revealed Resident #23 activated his call light at 11:04 A.M. and staff responded to his room at 11:32 A.M. Observation during this time period, over 10 staff members walked by the resident's room including the Director of Nursing (DON), the Social Worker, the Housekeeping Supervisor, along with several aides and nurses and no one answered the resident's call light. Observation at the same time revealed the visible light was illuminated outside the resident's room which indicated the call light was activated. Interview on 01/22/24 at 11:37 A.M. with State Tested Nursing Assistant (STNA) #215 revealed she was passing water and when she got to Resident #23's room, she realized the call light was on. STNA #215 revealed the call lights alerted on a screen at the nurse's station and also by a visible light outside the resident's room. STNA#215 revealed she was unaware of the call light going off for over 25 minutes. Interview on 01/22/24 at 5:30 P.M. with Corporate Administrator #250 revealed the call lights should be answered timely and revealed a call light in the 25-30-minute range was not acceptable. Call light audits were requested from Corporate Administrator #250 several times prior to and again at this interview and the facility was unable to provide any documented evidence of the call lights times and /or any audits completed. The subsequent interview on 01/23/24 at 11:24 A.M. with the DON reported the STNA who was responsible to care for Resident #23 when the call light was not timely answered on 01/22/23, was found to have left the facility and was sitting in her car. The DON revealed the agency STNA in question was placed on the do not return list. Review of facility policy titled Call Lights, dated 08/2023, revealed staff should promptly respond to calls for assistance to provide a safe environment and meet care needs. This deficiency represents non-compliance investigated under Complaint Number OH00149489. 365606 Page 8 of 10 365606 01/25/2024 Als Woodstock Inc 1649 Park Rd Woodstock, OH 43084

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 observation, staff interviews, resident interview, and record review, the facility failed to ensure residents received their diet as ordered. This affected one (#35) of three residents reviewed for nutrition. The facility census was 39. Findings include: Review of the medical record for the Resident #35 revealed an admission date of 11/26/20. Diagnoses included sepsis, morbid obesity, hyperlipidemia, gastro esophageal reflux disease (GERD), diabetes, intellectual disability, and muscle weakness. Review of a dietary note dated 10/03/22 revealed Resident #35 was recommended to receive half portioned meals for lunch and dinner. Review of a physician's order dated 10/04/22 revealed Resident #35 was ordered to receive half portioned meals. Review of a dietary note dated 12/20/23 revealed Resident #35 had stable weights and received half portion meals for lunch and dinner. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively intact with a Brief Interview Mental Status (BIMS) of 15 and required set up assistance from the staff for eating. Interview on 01/22/24 at 5:19 P.M. with Resident #35 and State Tested Nursing Assistant (STNA) #205 revealed the resident nor the staff were aware that the resident was ordered to receive half portioned meals. STNA #205 confirmed resident was served a regular portioned meal. Interview on 01/23/24 at 11:21 A.M. with Director of Nursing (DON) revealed Resident #35 was put on half portioned meals for lunch and dinner as a weight loss plan and verified the order was made on 10/2022. Review of facility policy titled therapeutic diets, dated 08/2023, revealed resident's diets are determined by the physician and dietician to support resident treatment and plan of care. 365606 Page 9 of 10 365606 01/25/2024 Als Woodstock Inc 1649 Park Rd Woodstock, OH 43084

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, resident interview, and record review, the facility failed to ensure a resident was provided with the appropriate assistive devices for dining. This affected one (#16) of three residents reviewed for assistive devices for dining. The facility identified eight (#05, #7, #14, #16, #17, #19, #36, and #39) residents with orders for adaptive equipment. The facility census was 39. Residents Affected - Few Findings include: Review of the medical record for the Resident #16 revealed an admission date of 06/24/16. Diagnoses included hemiplegia and hemiparesis unspecified cerebrovascular disease, bipolar disorder, dysphasia, and muscle weakness. Review of the plan of care dated 12/17/23 for Resident #16 revealed the resident was at risk for altered nutrition and hydration with interventions to offer encouragement, assistance and cueing as needed at mealtime, encourage to dine in the dining room, provide diet as ordered and the Dietician and Speech Therapy to evaluate as needed, Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively impaired with a Brief Interview Mental Status (BIMS) of six and required partial/moderate assistance with eating. The resident was dependent on staff for mobility and transfers. The assessment revealed the resident had no coughing or choking during meals or when swallowing medications. Interview with Resident #16 on 01/22/24 at 12:15 P.M. revealed he typically received a divided plate for meals. Observation at the same time, revealed the resident had a regular plate for the lunch meal service. The resident's meal ticket on his tray revealed the resident was to have a divided plate for meals. Interview with State Tested Nursing Assistant (STNA) #212 on 01/22/24 at 12:34 P.M. confirmed Resident #16 should have a divided plate and was not provided one for his lunch meal. Interview with Kitchen Manager #240 on 01/22/24 at 12:45 P.M. confirmed Resident #16 should be given a divided plate for all meals. Kitchen Manager #240 reported he was not aware that the resident was given a regular plate instead of the divided plate and provided no explanation as he reported that he did not participate in the tray line. Review of facility policy titled Adaptive Assisted Eating Devices, dated 2021, revealed the facility would provide special eating equipment, utensils and assistance as needed for meals. Residents would be assessed for therapeutic equipment for eating and a physician order would be placed. The order shall also be present on the meal ticket. 365606 Page 10 of 10