Inspection Report

Woodland Manor: Colostomy Care Failures Cited - IN

June 29, 2026

Elkhart, IN

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Federal inspectors cited the facility on September 15 after a complaint investigation found that staff failed to document colostomy care, failed to notify a physician of a severe depression score, and had no plan in place to address the resident's repeated removal of his own colostomy appliance.

The resident, identified in inspection records as Resident A, had ADHD and a colostomy that physician orders required staff to manage every shift. A nurse told inspectors the resident would spontaneously remove the bag and flange without telling anyone. The Assistant Director of Nursing confirmed it had happened before. The facility's own records showed stool output was logged only twice between September 2 and September 15, and routine colostomy care went undocumented on September 2.

On September 15, inspectors observed staff cleaning a large amount of stool from the front entrance of the facility. The administrator confirmed the resident had unsealed his colostomy near the front door.

The psychiatrist who saw Resident A on September 11 had no idea the resident had scored a 20 on his depression scale three weeks earlier, a score indicating severe depression. Staff had not documented the result or notified the physician between August 19 and August 25, when the score was completed. The psychiatry notes from September 11 contained no mention of the colostomy behavior either.

The Social Services Director told inspectors that all facility physicians had access to completed assessments and spoke with her weekly. She did not indicate the providers had been told about the colostomy behavior.

When inspectors asked for the facility's behavior identification and tracking policy, none was produced before they left.

The resident, staff said, wanted to move to assisted living and had been offered support groups, which he declined. He was physically and mentally capable of leaving the facility on his own.

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.

Download the official CMS inspection PDF from Medicare.gov

Additional Resources

Editorial Standards & Data Disclosure

Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.

Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.

Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.

Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.

Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.

Last verified: September 22, 2026 · Our methodology

Quick Answer

WOODLAND MANOR in ELKHART, IN was cited for violations during a health inspection on September 15, 2025.

The resident, identified in inspection records as Resident A, had ADHD and a colostomy that physician orders required staff to manage every shift.

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.

Frequently Asked Questions

What happened at WOODLAND MANOR?

The resident, identified in inspection records as Resident A, had ADHD and a colostomy that physician orders required staff to manage every shift.

How serious are these violations?

Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.

What should families do?

Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in ELKHART, IN, (5) Report any new concerns directly to state authorities.

Where can I see the full inspection report?

The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from WOODLAND MANOR or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 155086.

Has this facility had violations before?

To check WOODLAND MANOR's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.