Als Woodstock Inc
Inspection Findings
F-Tag F0880
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observation, staff interviews and policy review, the facility failed to follow infection control protocol when changing a wound dressing. This affected one (#19) of three residents reviewed for wound care. The facility census was 42. Findings include: Medical record review for Resident #19 revealed an admission on [DATE REDACTED] with diagnoses including rhabdomyolysis, hyponatremia, hypertension, heart disease, diabetes mellitus type two, personality disorder, convulsions, Rickets and right leg amputation. Review of
the Minimum Data Set (MDS) assessment dated [DATE REDACTED] for Resident #19 revealed an intact cognition.
Resident #19 required set up assistance for eating, supervision assistance for bed mobility and toileting.
Resident #19 requires extensive assistance for transfers. Resident #19 was coded as receiving wound care for diabetic ulcer during the look back period. 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.
Residents Affected - Few
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
Event ID:
ALS WOODSTOCK INC in WOODSTOCK, OH inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WOODSTOCK, OH, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ALS WOODSTOCK INC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.