Health inspection·June 17, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of a facility self-reported incident (SRI) and staff interviews, the facility failed to develop a plan of care to address a resident's behaviors. This affected one (#11) of three residents reviewed for care planning. The facility census was 42. Findings include: Review of medical record for Resident #11 revealed admission date of 04/23/25 with diagnoses including Diabetes Mellitus, stroke, ataxia following stroke, depression and anxiety. The resident was discharged on 06/05/25 to another skilled nursing facility. The discharge Minimum Data Set (MDS) dated [DATE] revealed with a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. The resident was required set up of touching assistance for Activities of Daily Living. Review of Resident #11's physician orders revealed an order dated 05/23/25 for one-on-one (1:1) supervision until further notice. Review of Resident #11's Health Status Note dated 06/01/25 at 8:54 A.M. revealed resident continues to be 1:1 with staff. No situations or concerns this morning shift. Will continue to monitor. A Health Status Note dated 06/01/25 at 5:31 P.M. revealed resident continues 1:1 care per staff member with no situations or issues to report for this. Resident #11 has been very compliant today with redirection when needed for simple tasks. A Health Status Note dated 06/03/25 at 5:53 P.M., revealed the resident was on strict 1:1 per order this shift. Further review of Resident #11's plan of care revealed there was no care plan or intervention for the resident's behaviors or related to 1:1 supervision. Review of a facility SRI dated 05/30/25 regarding sexual abuse revealed on 05/23/25, it was reported by staff that a Resident #11 made a gyration motion in the doorway of Resident #1's room. Resident #11 was immediately placed on 1:1 supervision. This Administrator advised him that he was not to go into any resident rooms without invitation. On 05/30/25, Resident #1's daughter came to take the resident to a medical appointment and resident divulged to her that Resident #11 had actually exposed himself. Police were called. An investigation was conducted the allegation was unsubstantiated by the facility. Interview on 06/17/25 at 3:32 P.M. with the Administrator revealed Resident #11 had inappropriate (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 2 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 06/17/2025 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)