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Complaint Investigation

Woodland Manor

Inspection Date: November 29, 2025
Total Violations 1
Facility ID 265749
Location SPRINGFIELD, MO
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Inspection Findings

F-Tag F0557

Resident Rights Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

During an interview on 11/29/25, at 3:35 P.M., CNA C said the following:-The resident had told him/her that CNA A was disrespectful when the CNA did not allow the resident to wear an incontinent brief to bed; -CNA

A told the resident that it was healthier for him/her to sleep without a brief. The resident was upset because he/she wanted to wear an incontinent brief, but he/she did not want to tell anyone because he/she was afraid of retaliation from CNA A;-CNA C said it appeared as though the night shift staff did not provide incontinent care to the resident all night and he/she told the nurse about the lack of care provided by CNA A. During an interview on 11/29/25, at 3:55 P.M., CNA D said the following:-There were some issues with night shift staff, specifically CNA A, not wanting or allowing the resident to sleep with an incontinent brief;-CNA A told the resident that it was better for him/her to sleep without anything covering his/her bottom, but the resident wanted to sleep in a brief;-The resident told CNA D that sleeping without a brief made him/her feel like he/she did not matter, like staff did not care, and it made him/her feel bad. During interviews on 11/29/25, at 3:45 P.M. and 5:25 P.M., the resident said the following:-He/she wanted to wear a brief to bed but CNA A told him/her it was better to not wear anything to bed;-The resident did not want to cause trouble, but he/she hated incontinence and many times the aides at night either did not change him/her often or sometimes they did not come in at all;-The resident sighed and said he/she guessed that CNA A let him/her decide if he/she wore a brief or not but really CNA A would just keep at him/her until the resident relented and because the resident just wanted to get along with everyone, he/she did not argue.-The resident said no other staff really had an issue with cleaning him/her, only CNA A. During an

interview on 11/29/25, at 5:27 P.M., Licensed Practical Nurse (LPN) E said if staff heard another staff member be disrespectful or rude to a resident, they should report it to the charge nurse or Director of Nursing (DON). He/she had not directly heard CNA A be disrespectful to any residents but heard stories from other CNAs like not providing incontinent care as often as he/she should. The LPN thought it was typical shift to shift rivalry. Staff should not tell residents that assisting them hurts their backs. During an

interview on 11/29/25, at 5:45 P.M., LPN F said the following:-If he/she heard a staff member be disrespectful to a resident, he/she would stop the interaction, talk to the staff member then let administration know;-He/she had heard CNA A's tone get a little sharp with residents before. And there was

a situation with a newer resident where the new resident did not want CNA A in his/her room. The resident would not tell the LPN specifics about what happened, but then a short time later he/she allowed the CNA back into his/her room;-Resident #1 had not said anything to the LPN about CNA A;-It would not be appropriate for any CNA to tell a resident that assisting him/her hurt their back nor would it be appropriate for staff to continue to try to change a resident's mind once they made a decision about something. During

an interview on 11/29/25, at 6:00 P.M., CNA A said the following:-Staff should not be disrespectful or treat residents in an undignified manner.-If he/she heard or noted staff treating residents in this manner, he/she would notify the charge nurse or administration.-The CNA said he/she may have said that his/her back hurt, but he/she did not say that the resident caused his/her back pain;-Sometimes the resident did not want to wear incontinent briefs to bed, and sometimes he/she did. During an interview on 11/29/25, at 7:10 P.M.,

the Administrator said it was not appropriate to tell a resident that the resident caused the staff member to hurt their back and if a resident wanted to wear a brief to bed, staff should not guilt a resident into doing something they did not want to do. Staff should tell administration if a resident told them or if they heard staff being disrespectful to residents. Complaint 2679768

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📋 Inspection Summary

WOODLAND MANOR in SPRINGFIELD, MO inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

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 SPRINGFIELD, MO, (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.
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