Woodland Manor

F-F600

2. Resident H did not have her call light answered timely in order to have to have her care needs met.

Cross Reference F 550

3. The posted staffing for 2/27/25 indicated there were 2 CNA's for Unit 1 and Unit 2. There were 39 residents residing on Unit 1 and Unit 2.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 18 155086 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 During an interview, on 2/28/25 at 12:18 P.M., QMA 3 indicated she was staying over to cover a call off for day shift and there had been no communication about a replacement from anyone. She indicated she was Level of Harm - Actual harm not offered a bonus.

Residents Affected - 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 floor, over 20 hours straight.

The Facility Assessment was received from the RN consultant on 2/27/25 at 11:59 A.M. The assessment was dated 12/9/24 and had been reviewed by the Quality Assurance team on 12/20/24.

The assessment indicated it would be used to:

.Inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs identified through resident assessments and plans of care; Consider specific staffing needs for each resident unit in the facility and adjust as necessary based on the changes to its resident population; average daily census (ADC) 56-72 . Resident Acuity Affecting Nurse Aides (including facility specific not already listed)

Assistance Provided with Dressing 35

Assistance Provided with Bathing 58

Assistance Provided with Transfers 27

Assistance Provided with Eating 5

Assistance Provided with Toileting 35

Assistance Provided with Mobility 29

Assistance Provided with Splint braces 2

Assistance Provided with Behavior symptoms 35 .

SERVICES AND CARE WE OFFER BASED ON OUR RESIDENT'S NEEDS

Activities of Daily Living Dressing, oral care, toileting, eating, bathing, bed mobility, transfers, ambulation .

Bowel and Bladder Three day void to assess incontinence and determine if a scheduled toileting program is required. Residents who meet the requirement are then place on a written toileting program including care planning.

Information about our staff .

INFORMATION ABOUT OUR STAFFING PATTERNS

Average Nurse Aide/Resident Ratio (Direct Care Staff) 1 to 6 .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 18 155086 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Administration

Level of Harm - Actual harm Staffing as described above is adequate as evidence by: All care requirements are met daily and by shift

Residents Affected - Few Although the facility assessment indicated the direct care staffing ration was to be at a 1 staff to 6 resident ration, the ratio observed on 2/27/2025 on the 100 and 200 units, during the day shift was at a 1 staff to 13 resident ratio. (2 CNAs and 1 nurse for 39 residents)

This citation relates to complaint IN00453989 and complaint IN00453447.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 18 155086 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 47419 potential for actual harm Based on observation, interview and record review, the facility staff failed to follow infection control Residents Affected - Few procedures for a resident on Enhanced Barrier Precautions (EBP) for 1 of 1 resident reviewed for infection control. (Resident M)

Finding includes:

During an observation on 2/28/2025 at 5:20 A.M., CNA 7 and QMA 8 provided peri-care for Resident M, who had an indwelling urinary catheter. Both the CNA and the QMA entered the room and donned gloves but did not don gowns. There was a sign on the wall next to the door in the hallway for Resident M's room that indicated the resident was on Enhanced Barrier Precautions.

During an interview on 2/28/2025 at 5:22 A.M., QMA 8 indicated 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 indicated, at the same time, she did not know the resident was on EBP isolation.

A record review was completed on 2/28/2025 at 5:54 A.M. for Resident M. Diagnoses included, but were not limited to, hemiparesis and hemiplegia to right side, hydronephrosis with ureteral stricture, chronic obstructive uropathy and vascular dementia.

An Annual Minimum Data Set (MDS) assessment, dated 2/5/2025, indicated Resident M's cognition was severely impaired, he was dependent for toileting, had an indwelling urinary catheter and needed substantial/maximal assist with bed mobility.

Physician Orders included, but were not limited to:

-12/3/2024 Enhanced Barrier Precautions - gown and gloves must be worn for the following care: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting. Device care or use: central line, urinary catheter, feeding tube, tracheostomy, wound care or any skin opening requiring a dressing.

A current Care Plan, initiated on 7/10/2024, indicated the resident was on EBP for an indwelling urinary catheter and staff should wear gown and gloves for personal hygiene, changing briefs or providing care for a urinary catheter.

During an interview on 2/28/2025 at 6:05 A.M., the Director of Quality Assurance indicated staff should have known the resident was on EBP and should have been wearing gowns.

On 2/28/2025 at 7:00 A.M., the Director of Quality Assurance provided evidence CNA 7 had received education on EBP on 2/11/2025 and QMA 8 had attended an inservice that included education on EBP on 12/19/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 18 155086 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 2/28/2025 at 9:05 A.M., a current policy titled, Enhanced Barrier Precautions, and dated August 2022, was provided by the Director of Quality Assurance. The policy indicated, .EBPs employ targeted gown and Level of Harm - Minimal harm or glove use during high contact resident care activities when contact precautions do not otherwise apply potential for actual harm 3.1-18(a)(2) Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 18 155086