Health inspection·January 22, 2025

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 medical record review, staff interview, and policy review, the facility failed to notify a resident representative of change of condition. This affected one (#39) out of the three residents reviewed for change of condition. The facility census was 39. Findings include: Review of the medical record for Resident #39 revealed an admission date of 04/20/21 with medical diagnoses of Alzheimer's disease, alcohol dementia, behavioral disturbances, Wernicke's encephalopathy, and peripheral vascular disease. Review of the medical record for Resident #39 revealed a quarterly Minimum Data Set (MDS) assessment, dated 01/01/25, which indicated Resident #39 had moderate cognitive impairment and required supervision with oral care, toilet hygiene, and bathing. The MDS indicated Resident #39 was independent with eating, bed mobility, and transfers. Review of the medical record for Resident #39 revealed a nurse's note, dated 11/26/24 at 1:40 P.M., which stated Resident #39 tested positive for Coronavirus Disease 2019 (COVID-19) and the physician was notified. Review of the medical record revealed no documentation to support Resident #39's representative was notified positive COVID-19 test result. Review of the medical record for Resident #39 revealed a nurse's note, dated 01/02/25 at 3:13 P.M. which stated Resident #39 had increased behaviors and the physician was notified and ordered Resident #39 to be sent to the hospital for evaluation. Review of the medical record revealed Resident #39 was sent to the hospital on [DATE] and returned to the facility on [DATE] at 5:54 P.M. Review of the medical record revealed no documentation to support the facility notified Resident #39's representative on 01/02/25 that Resident #39 was sent to the hospital. Review of the medical record for Resident #39 revealed a nurse's note, dated 01/03/25 at 11:32 A.M., which stated Resident #39's representative was notified Resident #39 was sent to the hospital for evaluation on 01/02/25. The note stated Resident #39's representative expressed concern that he was not notified of clinical changes. Interview on 01/21/24 at 3:50 P.M. with Regional Nurse #140 confirmed the medical record for Resident #39 did not contain documentation to support Resident #39's representative was notified on 11/26/24 of COVID-19 positive test results. Regional Nurse #140 also confirmed the medical record did not contain documentation to support Resident #39's representative was notified on 01/02/25 of Resident #39's transfer to the hospital for evaluation due to behaviors. (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 5 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 01/22/2025 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)