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Complaint Investigation

Woodland Manor

February 28, 2025 · Elkhart, IN · 343 S Nappanee St
Citations 1
CMS Rating 1/5
Beds 80
Provider ID 155086
Healthcare Facility
Woodland Manor
Elkhart, IN  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)  ·  18 pages
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

WOODLAND MANOR in ELKHART, IN — inspection on February 28, 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

FF600
Actual harm not offered a bonus. Few On 2/28/2025 at 3:35 P.M., before the survey exit, QMA 3 and LPN 6 were still observed working on the affected

During an interview, on 2/27/2025 at 3:09 p.m., CNA 12 indicated 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.

There were 10 showers on the day shift, and staff were too busy getting residents up, assisting with meals, and laying the residents down to complete showers.

During an interview, on 2/27/2025 at 3:10 p.m., CNA 11 indicated if there were 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.

During an interview, on 2/28/25 at 10:42 a.m. the Quality Assurance Director (QAD) indicated the facility usually did not have a lot of staff call-offs and they tried to replace them.

The DON, Administrator, and scheduler had been out sick, and the scheduler had just returned back to work today.

There had been staff call -offs for today and the scheduler was working to have staff come in to cover.

There was an LPN and QMA that were still working from the prior shift ,which had started at 6:30 P.M. on 2/27/25.

The QAD indicated if the facility could not find replacements for the staff who had been working greater than 16 hours already, then the corporate nurse would have to work on a medication cart.

The Corporate nurse was not seen working any unit.

The QAD indicated bonuses were offered to staff if they picked up shifts

155086

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 155086 B.

Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Manor 343 S Nappanee St Elkhart, IN 46514

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 ELKHART, IN, (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 WOODLAND MANOR or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

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

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.