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. Page 1 of 5 365606 365606 01/22/2025 Als Woodstock Inc 1649 Park Rd Woodstock, OH 43084

F 0580 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled, Change in Resident's Condition, reviewed August 2023, stated the facility shall notify the resident, his/her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition. The policy stated except in medical emergencies, notifications will be made timely of a change occurring in the residents medical/mental condition or status. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00161210. 365606 Page 2 of 5 365606 01/22/2025 Als Woodstock Inc 1649 Park Rd Woodstock, OH 43084

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff and resident interviews, review of the facility activity calendar, and review of the facility policy, the facility failed to ensure group activities were conducted as scheduled. This had the potential to affect 22 residents residing in the facility who regularly attend group activities, the facility identified 17 (#02, #03, #04, #05, #06, #08, #10, #14, #16, #19, #22, #24, #25, #26, #30, #34, and #35) residents who chose not to attend and/or are not physically able to attend group activities. The facility census was 39. Residents Affected - Some Findings include: Review of the activity calendar for 01/21/25 revealed documentation to support the facility had a group activity scheduled for 9:00 A.M. The activity planned was coffee time in the activity room. Review of the activity calendar on 01/21/25 at 10:30 A.M. revealed a planned group activity of exercise in the facility dining room. Observation on 01/21/25 at 9:07 A.M. revealed the activity room door to be closed and locked. Observation of the facility common areas and dining room revealed no group activity taking place. Observation on 01/21/25 at 9:23 A.M. revealed the activity room door to be closed and locked. Observation of the facility common areas and dining room revealed no group activity taking place. Observation with interview on 01/21/25 at 9:25 A.M. with Assistant Director of Nursing (ADON) #130 confirmed the 9:00 A.M. group activity planned for 01/21/25 had not occurred because the activity staff were out of the facility bringing a resident to an appointment. Interview on 01/22/25 at 7:30 A.M. with Licensed Practical Nurse (LPN) #100 confirmed group activities are canceled at times so the activity staff can bring residents to their appointments. Interview on 01/22/25 at 7:36 A.M. with Resident #29 confirmed group activities are canceled at times because there is not any activity staff in the building. Interview on 01/22/25 at 9:18 A.M. with Activity Director (AD) #135 confirmed the group activity on 01/21/25 at 9:00 A.M. did not start until after 10:30 A.M. because he was out of the building bringing a resident to an appointment. AD #135 confirmed the group activity of exercise planned for 01/21/25 at 10:30 A.M. did not occur because residents were having coffee in the activity room at that time. The facility identified 22 residents residing in the facility who regularly attend group activities and 17 (#02, #03, #04, #05, #06, #08, #10, #14, #16, #19, #22, #24, #25, #26, #30, #34, and #35) residents who chose not to attend and/or are not physically able to attend group activities. Review of the facility policy titled, Activities, reviewed August 2023, stated the facility was to provide activity programming to promote physical, mental and psychosocial well-being of each resident. Activity programs are designed to meet the interests of the residents and encourage independent and interaction in the community. This deficiency represents non-compliance investigated under Complaint Number OH00161210. 365606 Page 3 of 5 365606 01/22/2025 Als Woodstock Inc 1649 Park Rd Woodstock, OH 43084

F 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Potential for minimal harm Based on staff interviews, employee file reviews, and review of the facility Activity Director (AD) job description, the facility failed to ensure the employee in the role of AD was qualified as required. This had the potential to affect all 39 residents residing in the facility. The facility census was 39. Residents Affected - Many Findings include: Interview on 01/22/25 at 9:18 A.M. with AD #135 confirmed he was hired at the facility as the AD on October 15, 2024, and was currently enrolled in an activity training course. AD #135 confirmed he was not a qualified therapeutic specialist or an activities professional who was licensed by the state or had a minimum of two years' experience in social or recreational program within the past five years or was a qualified occupational therapist or occupational therapist assistant or completed a training course approved by the State. Interview on 01/22/25 at 9:30 A.M. with Regional Nurse #140 confirmed the employee in the role of AD was currently enrolled in a training course for activities certification and had started some of the online training but had not completed the course yet. Interview on 01/22/25 at 9:50 A.M. with Administrator stated she is a contracted employee and was hired at the facility on 11/27/24 and oversaw the activities department. Administrator stated she had completed the certification for activities prior to starting at the facility. Administrator confirmed the facility contract for her employee did not contain documentation to support her role as the AD. Review of the facility Activity Director job description the purpose of the position was to plan, organize, develop, and direct he overall operations of the Activities Department in accordance with current federal, state, and local standards, guidelines, and regulations, our established policies and procedures, and as may be directed by the Administrator, to assure that an on-going program of activities is designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. The policy stated the qualifications for the position included: must possess a high school diploma and must be a qualified therapeutic specialist or an activities professional who is licensed by the state and is eligible for certification as a recreation specialist or as an activities professional; or must have, as a minimum of two years' experience in social or recreational program within the past five years, one o which was full-time in a patient activities program in a health care setting; or must be a qualified occupational therapist or occupational therapist assistant; or must have completed a training course approved by the State. Review of the employee file for AD #135 revealed a hire date of 10/15/24. The employee file contained confirmation form with enrollment into activity training course but no documentation to support he completion of the course. Review of the employee file for Administrator revealed a company contract which stated Administrator was hired effective 11/27/24. The contract did not contain documentation to support that the Administrator would also serve as the AD. Review of the file revealed documentation to support Administrator had completed the AD's course on 11/04/05. 365606 Page 4 of 5 365606 01/22/2025 Als Woodstock Inc 1649 Park Rd Woodstock, OH 43084

F 0680 This deficiency was based on incidental findings discovered during the course of this complaint investigation. Level of Harm - Potential for minimal harm Residents Affected - Many 365606 Page 5 of 5