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 Page 1 of 2 365606 365606 06/17/2025 Als Woodstock Inc 1649 Park Rd Woodstock, OH 43084

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few behaviors and an allegation of misappropriate sexual behavior by Resident #11 toward Resident #1 which prompted an order for 1:1 supervision. The Administrator stated Resident #11 was not a registered sexual offender but the facility was aware of a pending court hearing for sexual misconduct for Resident #11 prior to his admission. Interview on 06/17/25 at 4:16 P.M. with MDS Coordinator #109 revealed she was aware of an allegation of sexual misconduct by Resident #11 and she verified there was no behavioral care plan. MDS Coordinator #109 confirmed Resident #11 had behaviors and acknowledged given the 1:1 supervision order a behavioral care plan should have been created. This deficiency is based on incidental findings discovered during the course of this complaint investigation. 365606 Page 2 of 2