QMA 3 and LPN 6 were still observed working on the floor at 3:35 p.m. on February 28, more than 20 hours after their shifts began at 6:30 p.m. the previous evening. QMA 3 told inspectors at 12:18 p.m. that she was staying over to cover a call-off for day shift and "there had been no communication about a replacement from anyone."
She wasn't offered a bonus for the extended shift.
The staffing crisis left just two certified nursing assistants to care for 39 residents on Units 1 and 2 during the day shift — a ratio of one aide to nearly 20 residents. The facility's own assessment from December 2024 called for a ratio of one aide to six residents.
CNA 12 explained the consequences during an interview: "If there are three aides on Unit 1 and 2, then the showers could get done. If there were just two aides, then not all of them (showers) were completed." Staff were "too busy getting residents up, assisting with meals, and laying the residents down" to complete the 10 scheduled showers.
CNA 11 confirmed the pattern was routine. With three aides assigned, showers were provided, "but any less than three aides, the assigned work could not be completed and this occurred all the time."
The Quality Assurance Director acknowledged the facility "usually did not have a lot of staff call-offs" but explained that the Director of Nursing, Administrator, and scheduler had all been out sick. The scheduler had just returned to work that day and was "working to have staff come in to cover."
If replacements couldn't be found for staff who had already worked more than 16 hours, the corporate nurse would have to work a medication cart, the QAD said. Inspectors never observed the corporate nurse working any unit.
Meanwhile, staff who were present ignored basic infection control procedures. At 5:20 a.m. on February 28, inspectors watched CNA 7 and QMA 8 provide personal care for Resident M, who had an indwelling urinary catheter and was on Enhanced Barrier Precautions.
Both staff members entered the room and put on gloves but didn't wear gowns. A sign on the wall next to the door clearly indicated the resident was on Enhanced Barrier Precautions.
QMA 8 told inspectors that "staff never wore gowns for Resident M and she did not know the resident was on EBP even though he had a urinary catheter and a sign was present in the hall." CNA 7 also said she didn't know the resident was on isolation precautions.
Resident M's physician orders from December 3, 2024, specifically required gown and gloves for dressing, bathing, transferring, changing linens, providing hygiene, changing briefs, assisting with toileting, and any device care involving his urinary catheter.
His care plan, initiated in July 2024, repeated the requirement that staff wear gowns and gloves for personal hygiene, changing briefs, or providing care for the urinary catheter.
The Director of Quality Assurance acknowledged that "staff should have known the resident was on EBP and should have been wearing gowns." Records showed CNA 7 had received education on Enhanced Barrier Precautions on February 11, 2025, and QMA 8 had attended training that included EBP education on December 19, 2024.
The facility's own assessment, completed in December 2024, painted a picture of comprehensive care capabilities. It listed 58 residents requiring assistance with bathing, 35 needing help with dressing and toileting, and 35 with behavior symptoms requiring specialized attention.
The assessment claimed staffing was "adequate as evidence by: All care requirements are met daily and by shift."
But inspectors found the opposite. Resident H didn't have her call light answered in a timely manner. Scheduled showers went uncompleted when staffing dropped below three aides. Staff worked marathon shifts exceeding 20 hours while basic infection control protocols were ignored despite clear signage and recent training.
The facility offered bonuses to staff who picked up extra shifts, but QMA 3 wasn't offered one despite working through the night and well into the next afternoon.
The inspection was conducted in response to two complaints filed with state regulators about conditions at the 343 S Nappanee Street facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodland Manor from 2025-02-28 including all violations, facility responses, and corrective action plans.