Woodland Manor: Colostomy Care Failures Cited - IN
The resident, identified in inspection records only as Resident A, had a colostomy and a documented history of removing the bag himself, sometimes with the flange still attached. According to a licensed practical nurse interviewed that day, he would do it spontaneously and not tell staff. When the bag was full, he would carry it detached from the flange to the nurses' station himself.
That behavior had been happening long enough that multiple staff members knew about it. The Assistant Director of Nursing confirmed he had taken the colostomy off in the past. The administrator confirmed he had unsealed it and emptied stool on the floor near the front entrance. An RN said the bag had needed emptying two or three times during most shifts.
What no one had done was write it down in any systematic way, or build a plan around it.
Resident A's care plan, dated August 11, 2025, did not address his ADHD diagnosis or the colostomy removal behavior. There were no interventions. A physician order from March required staff to complete colostomy care every shift and empty the bag as needed. Task records for September showed that routine colostomy care was not documented as completed on September 2 during the day shift. Stool output, which should have been tracked through a bowel elimination flowsheet, was recorded only twice between September 2 and September 15, on the 4th and the 12th.
The documentation failures extended to his mental health as well. Resident A scored a 20 on a depression scale completed on August 21, a score that indicates severe depression. His psychiatrist, who saw him on September 11, had not been told. Progress notes from August 19 through August 25 showed staff had not notified the physician of the result during that window either. The psychiatry notes from September 11 contained no mention of the colostomy removal behavior, and no notes from that period documented staff reminding him not to unseal the bag.
The Social Services Director told inspectors that all facility physicians had access to all assessments completed by staff and spoke with the Social Services Director weekly. She did not indicate the providers had been told about the colostomy behavior.
The same director noted that on July 1, staff had witnessed Resident A drinking alcohol and driving his wheelchair recklessly. The physician was notified of that incident on July 2. The colostomy removals, which were happening across multiple shifts and had culminated in stool on the facility floor, had not prompted the same response.
The Assistant Director of Nursing told inspectors that Resident A wanted to be independent and had a plan to move to assisted living. He was capable of emptying the bag himself but had not been consistent about doing so. He had been offered support groups and refused them. The Social Services Director said he was mentally and physically capable of leaving the facility and had used his call light to reach staff.
None of that context appeared in a care plan. There were no documented education sessions about colostomy care. There were no notes about what staff said to him when he removed the bag, or how often they reminded him not to unseal it. The RN said regular education had been provided about telling staff when the bag was full, but the inspection report found no documentation of when that happened or what it covered.
Inspectors requested the facility's policy on behavior identification and tracking. No policy was provided before they left.
The citation covered the period from at least early August through the inspection date of September 15. By that afternoon, a man with severe depression, a colostomy he was removing without warning, and no written plan of care was still living in a facility where the most concrete record of his condition was the stool inspectors watched staff rinse from the front entrance floor.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodland Manor from 2025-09-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 29, 2026 · Our methodology
WOODLAND MANOR in ELKHART, IN was cited for violations during a health inspection on September 15, 2025.
According to a licensed practical nurse interviewed that day, he would do it spontaneously and not tell staff.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.