Als Woodstock Inc
ALS WOODSTOCK INC in WOODSTOCK, OH — inspection on September 10, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the plan of care for dated 06/30/25 for Resident #19 revealed resident is at risk for experiencing an alteration in skin related to diabetic foot ulcer.
Interventions include administer medications as ordered, monitor for side effects, assess, record and monitor healing as ordered, monitoring nutritional status, and pressure reducing devices.
Review of the active physician orders for Resident #19 revealed an order for enhanced barrier precautions (EBP) due to right elbow wound every shift dated 07/22/25 and an order for right elbow: cleanse with wound cleanser, pat dry, apply collagen (cut to fit wound bed), silver alginate (cut to fit wound bed and cover with bordered foam dressing one time a day dated 09/09/25.
Observation on 09/09/25 at 1:30 P.M. of wound care by Licensed Practical Nurse (LPN) #11 revealed the LPN entered room and advised Resident #19 of the task. LPN #11 removed old dressing to Resident #19's right posterior elbow, discarded dressing and completed hand hygiene. LPN #11 cleansed wound and applied dressings as ordered. LPN #11 dated and initialed dressing, removed gloves and completed hand hygiene.
The observations revealed LPN #11 did not don personal protective equipment (PPE) while providing care to Resident #19.
Interview on 09/09/25 at 4:29 P.M. with LPN #11 verified that she was unaware of Resident #11 being in EBP. LPN #11 stated the roommate had an infection and the EBP in place was for him. LPN #11 stated the EBP sign on the door of the room did not indicate which resident was in the EBP. LPN #11 verified she did not wear the required gown when completing the wound care for Resident #19 and should have.
Interview on 09/10/25 at 11:30 A.M. with the Director of Nursing (DON) verified the EBP sign at the entrance of Resident #19 failed to identify which resident in the double occupancy room was in the EBP and should have. DON illustrated the corrected sign that was going to be placed on the doors of the residents in EBP.
Review of the facility policy titled Enhanced Barrier Precautions dated 04/01/24 stated the EBP referred to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care.
Additionally, the policy stated EBP should be initiated for wounds that are chronic in nature that require a dressing.
This deficiency represents non-compliance investigated under Complaint Number 2597177.
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.
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