Health inspection·June 27, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, review of the medical record, review of the police report, review of the hospital documentation, and review of the facility's wandering and exit-seeking policy and procedure, the facility failed to provide a safe environment and adequate supervision to prevent Resident #8 from exiting the facility without staff knowledge. This affected one (Resident #8) of three residents reviewed for elopement. The facility identified six residents (Resident #8, #19, #20, #23, #25, and #33) at risk for elopement. The facility census was 39. Findings include: Review of Resident #8's medical record revealed he was admitted to the facility on [DATE] with diagnoses including pulmonary nodule, metastatic squamous cell carcinoma, and emphysema. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #8 had severe cognitive impairment, required contact guard assistance from staff with ambulation, exhibited wandering behaviors, and required an elopement alarm. Review of Resident #8's care plan dated 12/02/23 revealed he was at risk of elopement with a wanderguard placed on his left ankle. Interventions included educating family on elopement risks and interventions, utilizing wander guard for safety, and employing distractions to help decrease wandering. Review of the physician orders for Resident #8 revealed an order dated 05/16/24 for WanderGuard (Secure Care device) placement on the left ankle due to increased wandering. Review of Resident #8's elopement assessment dated [DATE] revealed he had a history of wandering and attempting to leave the facility unattended, and he had voiced the desire to go home. Review of the facility incident report revealed on 06/22/24 at 7:30 A.M., Resident #8 had an event of wandering/elopement. Resident #8 was unable to be located within the facility. On 06/22/24 at 7:45 A.M., nursing staff implemented an internal and external search for this resident. The Director of Nursing (DON) was notified immediately; the DON notified the Administrator. Staff were delegated to continue the search and immediately notify the police department and family. When Resident #8 was found, his mental state was at baseline; he denied having pain and had no visible injuries. Review of the timeline of events undated revealed on 06/22/24 at 7:45 A.M., Resident #8 was identified as missing. The internal and external search began at 7:45 A.M. Staff members conducting the search were Licensed Practical Nurse (LPN) #109, LPN #151, and LPN #152, State Tested Nursing Assistant (STNA) #102 and STNA #152. Non-direct care staff present were Housekeeping Aide (HA) #141, HA #143, (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 3 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 06/27/2024 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)