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Home / Indiana / Elkhart

Woodland Manor

343 S Nappanee St., Elkhart, IN 46514 · Elkhart County · (574) 295-0096

80 certified beds, about 68 residents a day · For profit - Corporation · Medicare and Medicaid since 1969

Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
1 of 5
Staffing
1 of 5
CMS note: This facility reported a high number of days without a registered nurse onsite.
Quality measures
1 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 155086 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on November 21, 2025, inspectors cited 9 health deficiencies (the Indiana average is 7.2, the national average 9.2).

Of 48 health citations since December 2023, 5 were rated as actual harm or immediate jeopardy to residents.

CMS lists 2 fines totaling $114,339 in the last three years; the largest was $79,284, and the latest is dated February 28, 2025.

Nurses and nurse aides worked 3.53 hours per resident per day, against 3.69 across Indiana and 3.86 nationally. Registered nurses accounted for 0.31 of those hours.

69.5% of nursing staff left within the year CMS measured (Indiana average 45.9%).

CMS links it to Adams County Memorial Hospital, an affiliated group of 9 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 48 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
5G
0H
0I
Potential for more than minimal harm
31D
9E
2F
Potential for minimal harm
0A
0B
1C
November 21, 2025Standard inspection · 9 citations
  1. E
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    F921 · Environmental · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) December 24, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, and clean environment related to dirty floors in the laundry rooms; cracked and buckled flooring in the 100, 200, and 300 units; and non-functioning electrical outlets.
  2. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 24, 2025
    Inspectors wroteBased on observation, interview and record review, the facility failed to notify the physician of a resident's change in condition related to blood pressure, missed doses of medication and blood sugar for 2 of 3 residents review for physician notification. (Residents 71 and 34)
  3. D
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    F605 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 24, 2025
    Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the correct dosage of an antipsychotic was ordered after a failed gradual dose reduction for 1 of 5 residents reviewed for unnecessary medications. (Resident 22)
  4. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 24, 2025
    Inspectors wroteBased on Interview and record review, the facility failed to hold quarterly care plan conferences and include the resident, or resident representative for 1 of 19 residents whose care plans were reviewed. (Resident 3)
  5. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 24, 2025
    Inspectors wroteBased on observation, record review and interview, the facility failed to identify skin conditions for 1 of 2 residents reviewed for skin conditions (Resident 8) and failed to administer blood pressure medications according to the ordered parameters for 1 of 5 residents reviewed for unnecessary medications (Resident 44).
  6. D
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    F757 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 24, 2025
    Inspectors wroteBased on observation, record review and interview, the facility failed to obtain ordered laboratory tests for 1 of 5 residents reviewed for unnecessary medications. (Resident 22)
  7. D
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    F770 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 24, 2025
    Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory services were obtained timely for 1 of 5 residents whose labs had been reviewed. (Resident 31)
  8. D
    Provide or obtain dental services for each resident.
    F791 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 24, 2025
    Inspectors wroteBased on record review, record review and interview, the facility failed to ensure the recommended dental services was completed timely for 1 of 1 resident reviewed for dental services. (Resident 22)
  9. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 24, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices related to urinary catheters for 1 of 3 residents reviewed for urinary catheters. (Resident 3)
September 15, 2025Complaint inspection · 1 citation
  1. D
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    F742 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 26, 2025
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure behaviors were care planned, monitored and evaluated for 1 of 2 residents reviewed. (Resident A)During an observation on 9/15/25 at 10:09 AM the following was observed:Resident A was resting on his bed with the head of the bed elevated. The colostomy bag on the resident's left side of the abdomen was bent at an angel more than 90 degrees and ballooning to the shape of the colostomy bag. In an interview, on 9/15/25 at 10:10 AM, Resident A indicated his colostomy bag had opened unexpectedly in the past. He indicated staff only emptied the bag every couple of days and only when he would tell the staff it needed emptied. He indicated he would take care of the bag himself and hand the bag to the nurses. Resident A indicated caring for the colostomy made him anxious. [...]
May 5, 2025Standard inspection · 7 citations
  1. D
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    F623 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 23, 2025
    Inspectors wroteBased on record review and interview, the facility failed to ensure residents were provided proper notice prior to an involuntary transfer or discharge for 1 of 4 residents reviewed for hospitalizations (Resident 49).
  2. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 23, 2025
    Inspectors wroteBased on observation, interview and record review, the facility failed to provide showers for 1 of 7 residents reviewed for ADL (Activities of Daily Living) care. (Resident 1)
  3. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 23, 2025
    Inspectors wroteBased on record review and interview, the facility failed to notify the physician of abnormal blood sugars for 1 of 1 resident reviewed for insulin usage. (Resident 3)
  4. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 23, 2025
    Inspectors wroteBased on observation, record review and interview, the facility failed to store respiratory equipment in a sanitary manor for 2 of 3 residents reviewed for respiratory care. (Resident 1 & 50)
  5. D
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 23, 2025
    Inspectors wroteBased on observation, record review and interview, the facility failed to attempt a gradual dose reduction of an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 20)
  6. D
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 23, 2025
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication storage areas were clean and free from loose medications and failed to ensure medications were labeled and dated when opened, during medication storage review in 2 of 2 medication carts reviewed. (medication cart 1 on 100/200 hall and Memory Care 400 medication cart).
  7. C
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    F576 · Resident Rights · No actual harm, potential for minimal harm, widespread · Corrected (the home has a date of correction) May 23, 2025
    Inspectors wroteBased on interview and record review, the facility failed to provide mail delivery on Saturdays. This deficient practice affected 10 of 10 residents who attended the resident /surveyor group meeting.
February 28, 2025Complaint inspection · 5 citations
  1. G
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 21, 2025
    Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident was not neglected (Resident T) and the facility failed to complete interventions in place to prevent neglect and abuse (Resident P and Q) for 3 of 4 residents reviewed for abuse. (Residents T, P & Q) . This deficient practice resulted in Resident T observed to be extensively incontinent of urine and bowel movement (BM), including his clothing, bed pad, sheet, and blanket and had not received incontinent care for an undetermined amount of time. In addition, using the reasonable person concept, resident T and Q could have had feelings of embarrassment, fear of neglect, hopelessness, or depression related to the lack of superivision. (Resident P and Q)
  2. G
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 28, 2025
    Inspectors wroteBased on record review and interview, the facility failed to prevent and identify pressure injuries for 2 of 3 residents reviewed for pressure injuries (Residents E & F). The deficient practice resulted in wounds developed to a Stage 3 pressure ulcer for Resident E and an unstageable wound for Resident F.
  3. G
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    F725 · Nursing and Physician Services · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 21, 2025
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there were staff available to provide care in a timely manner to residents who required assistance(Resident T and H) and failed to ensure staff did not work greater than 20 hours in a day. (QMA 3 and LPN 6) Using the reasonable person concept, resident T could have feelings of embarrassment, fear of neglect, hopelessness, or depression.
  4. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 21, 2025
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's call light was answered timely and care was provided to maintain her dignity for 1 of 4 residents who were reviewed for dignity. (Resident H)
  5. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 28, 2025
    Inspectors wroteBased on observation, interview and record review, the facility staff failed to follow infection control procedures for a resident on Enhanced Barrier Precautions (EBP) for 1 of 1 resident reviewed for infection control. (Resident M)
November 14, 2024Standard inspection, Complaint inspection · 18 citations
  1. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 24, 2025
    Inspectors wroteBased on interview, record review and interview, the facility failed to ensure showers were provided for 3 of 7 residents reviewed for ADL's (Activities of Daily Living). (Residents 53, E & F)
  2. F
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    F921 · Environmental · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) December 14, 2024
    Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a sanitary environment related to urine odors, dirty ceilings and walls and unpainted spackle in resident's rooms and related to gouges and unpainted spackle on the 400 unit hall walls.
  3. F
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    F925 · Environmental · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) December 14, 2024
    Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective Pest Control Program related to an infestation of fruit flies. This had the potential to affect 68 of the 68 residents who reside in the facility.
  4. E
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) January 24, 2025
    Inspectors wroteBased on record review and interview, the facility failed to notify the physician timely of changes for blood glucose readings outside of the ordered parameters for 2 of 3 residents reviewed for insulin usage (Resident 30 & M), for 1 of 2 residents reviewed for death (Resident H) and for 1 of 3 residents reviewed for accidents (Resident 12).
  5. E
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    F623 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) December 14, 2024
    Inspectors wroteBased on record review and interview, the facility failed to ensure a transfer/discharge form was provided for 4 of 4 residents reviewed for hospitalization. (Residents B, 52, 55, 69)
  6. E
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    F625 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) December 14, 2024
    Inspectors wroteBased on record reviews and interview, the facility failed to provide a bed hold form for 4 of 4 residents reviewed for hospitalizations. (Resident 52, 55, 69 & B)
  7. E
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) January 24, 2025
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the environment was free from potential hazards for 1 of 4 halls. In addition, the facility failed to ensure interventions were in place to prevent burns for 1 of 3 residents reviewed for accidents. (Resident 12)
  8. E
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) December 14, 2024
    Inspectors wroteBased on observation, interview and record review, the facility failed to adequately label an over the counter medication stored in a medication cart for 1 of 1 medication cart reviewed (400 Unit). The facility also failed to monitor and maintain proper temperatures of a refrigerator where medications were stored for 1 of 1 medication refrigerators reviewed (Nurses Station 1).
  9. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) December 14, 2024
    Inspectors wroteBased on observation, record review and interview, the facility failed to ensure 1 of 2 unit pantries was maintained in a sanitary manner. This had the potential to affect 18 of 18 residents on the 400 unit.
  10. D
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    F622 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 14, 2024
    Inspectors wroteBased on record review and interview, the facility failed to ensure pertinent transfer and resident clinical information was completed for neccessary hospital transfers for 1 of 4 residents reviewed for hospitalization. (Resident B)
  11. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 26, 2024
    Inspectors wroteBased on observation, record review and interviews, the facility failed to develop a comprehensive person-centered care plan for activities (Resident 54) and medication use (Resident 64) for 2 of 27 residents reviewed for care plans (Resident E) .
  12. D
    Provide activities to meet all resident's needs.
    F679 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 14, 2024
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were provided with activities designed to meet their interest and their physical, mental, and psychosocial well-being for 1 of 4 residents reviewed for activities (Resident 54).
  13. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 24, 2025
    Inspectors wroteBased on record review and interview, the facility failed to ensure physician orders for extra fluids were discontinued timely. This deficient practice resulted in the resident developing bilateral lower extremity edema requiring the use of diuretic medication. (Resident M)
  14. D
    Assist a resident in gaining access to vision and hearing services.
    F685 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 14, 2024
    Inspectors wroteBased on record review and interview, the facility failed to ensure a resident with impaired vision received the appropriate follow-up care for 1 of 1 residents reviewed for communication (Resident 35).
  15. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 24, 2025
    Inspectors wroteBased on record review, interview and observation, the facility failed to ensure physician ordered medications were available for 3 of 24 residents whose medications were reviewed. (Residents E, L and M)
  16. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 24, 2025
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control practices were followed related to glove use and handwashing during perineal and catheter care for 1 of 2 residents observed for catheter care. (Resident 50)
  17. D
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    F883 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 24, 2025
    Inspectors wroteBased on record review and interview, the facility failed to provide a resident with a pneumococcal vaccination timely for 1 of 5 residents reviewed for vaccinations. (Resident 11)
  18. D
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    F887 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 24, 2025
    Inspectors wroteBased on record review and interview, the facility failed to provide consented vaccinations for 1 of 4 residents reviewed for immunizations. (Resident 101)
September 6, 2024Complaint inspection · 1 citation
  1. D
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    F698 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 27, 2024
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 1 residents who required dialysis, received assessment/monitoring for complications prior to and/or after their dialysis treatments, according to the facility policy and the resident's plan of care. (Resident D)
June 21, 2024Complaint inspection · 1 citation
  1. G
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 19, 2024
    Inspectors wroteBased on record review, and interview the facility failed to ensure the Memory Care Unit (MCU) was free from incontinence brief debris and failed to ensure adequate supervision was provided to a cognitively impaired resident on the MCU to prevent ingestion of the debris for 1 of 3 residents reviewed for accidents. This deficient practice resulted in Resident C experiencing a blocked airway, a change in level of consciousness and requiring emergent treatment from Emergency Medical Services (EMTs). (Resident C)
June 14, 2024Complaint inspection · 1 citation
  1. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 5, 2024
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received adequate supervision and the facility's elopement policy was followed for a resident with a traumatic brain injury with cognitive deficits, who was transferred off facility property, to a physician's office appointment, (Resident B)
May 17, 2024Complaint inspection · 2 citations
  1. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) July 5, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, served and delivered in a sanitary manner in 1 of 1 kitchens. This had the potential to affect 67 of 67 residents who consumed food from the kitchen.
  2. E
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    F925 · Environmental · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) July 5, 2024
    Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program related to gnats in residents rooms and in common areas in the facility in 1 of 4 units observed for environment. (200 Hall).
March 6, 2024Complaint inspection · 1 citation
  1. G
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 8, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident C, a resident with dementia, was free from resident-to-resident sexual abuse by Resident B, for 2 of 2 residents reviewed for sexual abuse. Using the reasonable person concept, it is likely this would lead to fear, confusion and anxiety for Resident C.
December 21, 2023Complaint inspection · 2 citations
  1. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 12, 2024
    Inspectors wroteBased on interview and record review, the facility failed to notify the responsible party of a transfer to the emergency room for 1 of 3 residents reviewed for transfer and discharge. (Resident D)
  2. D
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    F622 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 12, 2024
    Inspectors wroteBased on interview and record review, the facility failed to ensure the correct clinical information was provided to a receiving hospital that was necessary to meet a resident's needs and ongoing care, for 1 of 3 residents reviewed for transfer and discharge, (Resident D).

Fire safety inspections

28 fire safety citations on file: 4 on November 21, 2025, 7 on May 5, 2025, 17 on November 14, 2024.

Every fire safety citation28 citations
  1. F
    Have simulated fire drills held at unexpected times.
    K 712 · November 21, 2025 · Corrected (the home has a date of correction)
  2. E
    Install corridor and hallway doors that block smoke.
    K 363 · November 21, 2025 · Corrected (the home has a date of correction)
  3. C
    Implement emergency and standby power systems.
    E 41 · November 21, 2025 · Corrected (the home has a date of correction)
  4. C
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · November 21, 2025 · Corrected (the home has a date of correction)
  5. F
    Meet other general requirements that are deficient.
    K 300 · May 5, 2025 · Corrected (the home has a date of correction)
  6. F
    To conduct inspection, testing and maintenance of fire doors by qualified individuals.
    K 761 · May 5, 2025 · Corrected (the home has a date of correction)
  7. F
    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
    K 914 · May 5, 2025 · Corrected (the home has a date of correction)
  8. F
    Ensure that testing and maintenance of electrical equipment is performed.
    K 921 · May 5, 2025 · Corrected (the home has a date of correction)
  9. E
    Provide properly protected cooking facilities.
    K 324 · May 5, 2025 · Corrected (the home has a date of correction)
  10. E
    Have properly installed electrical wiring and gas equipment.
    K 511 · May 5, 2025 · Corrected (the home has a date of correction)
  11. C
    Have approved installation, maintenance and testing program for fire alarm systems.
    K 345 · May 5, 2025 · Corrected (the home has a date of correction)
  12. F
    Develop and maintain an Emergency Preparedness Program (EP).
    E 4 · November 14, 2024 · Corrected (the home has a date of correction)
  13. F
    Address patient/client population and determine types of services needed.
    E 7 · November 14, 2024 · Corrected (the home has a date of correction)
  14. F
    Develop Emergency Preparedness policies and procedures.
    E 13 · November 14, 2024 · Corrected (the home has a date of correction)
  15. F
    Establish procedures for tracking staff and patients during an emergency.
    E 18 · November 14, 2024 · Corrected (the home has a date of correction)
  16. F
    Develop a communication plan.
    E 29 · November 14, 2024 · Corrected (the home has a date of correction)
  17. F
    Provide primary/alternate means for communication.
    E 32 · November 14, 2024 · Corrected (the home has a date of correction)
  18. F
    Provide family notifications of emergency plan.
    E 35 · November 14, 2024 · Corrected (the home has a date of correction)
  19. F
    Establish emergency prep training and testing.
    E 36 · November 14, 2024 · Corrected (the home has a date of correction)
  20. F
    Establish staff and initial training requirements.
    E 37 · November 14, 2024 · Corrected (the home has a date of correction)
  21. F
    Conduct testing and exercise requirements.
    E 39 · November 14, 2024 · Corrected (the home has a date of correction)
  22. F
    Have simulated fire drills held at unexpected times.
    K 712 · November 14, 2024 · Corrected (the home has a date of correction)
  23. E
    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
    K 321 · November 14, 2024 · Corrected (the home has a date of correction)
  24. E
    Provide properly protected cooking facilities.
    K 324 · November 14, 2024 · Corrected (the home has a date of correction)
  25. E
    Properly select, install, inspect, or maintain portable fire extinguishes.
    K 355 · November 14, 2024 · Corrected (the home has a date of correction)
  26. E
    Install corridor and hallway doors that block smoke.
    K 363 · November 14, 2024 · Corrected (the home has a date of correction)
  27. E
    Install smoke barrier doors that can resist smoke for at least 20 minutes.
    K 374 · November 14, 2024 · Corrected (the home has a date of correction)
  28. E
    Ensure proper usage of power strips and extension cords.
    K 920 · November 14, 2024 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
February 28, 2025Fine $79,284
May 17, 2024Fine $35,055
May 17, 2024Payment Denial 29 days from June 20, 2024

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeIndianaUnited States
All nursing staff (RN, LPN and aides)3.533.693.86
Registered nurses0.310.670.69
All nursing staff on weekends3.133.253.42
Nurse aides2.14
Licensed practical nurses1.08
Nursing staff turnover (share who left in a year)69.5%45.9%45.8%
Registered nurse turnover75.0%40.3%42.9%
Administrators who leftnot reported

CMS expects 4.28 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.69 on weekdays and 3.13 on weekends, 15% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.1% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.62 in April to June 2025 to 3.53 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.530.313.693.13 0.1%9 of 9068
Oct to Dec 20253.530.343.663.18 0.2%3 of 9269
Jul to Sep 20253.780.453.963.31 0.0%1 of 9270
Apr to Jun 20253.620.333.763.28 3.6%0 of 9171
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Indiana, Jan to Mar 20263.630.623.803.193.4%0.4% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeIndianaUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
37.311.013.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.80.40.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
2.71.11.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
1.53.93.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
1.71.21.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
35.511.914.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
0.43.64.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
23.713.615.4

Owners and operators

Legal business name: ADAMS COUNTY MEMORIAL HOSPITAL. CMS links this home to Adams County Memorial Hospital, a group of 9 nursing homes averaging 2.9 stars overall.

NameRoleTypeShareSince
Cibc Bank USA5% or greater mortgage interestOrganization11/01/2020
Borne-Bauman, CandiceManaging control - governing bodyIndividual01/01/2019
Flueckiger, RussellManaging control - governing bodyIndividual05/01/2015
Lehman, ScottManaging control - governing bodyIndividual07/14/2020
Macklin, LarryManaging control - governing bodyIndividual05/01/2015
McIntire, DavidManaging control - governing bodyIndividual01/01/2019
Adams County Memorial HospitalOperational/managerial controlOrganization05/01/2012
Woodland Nursing and Rehab LLCOperational/managerial controlOrganization11/01/2020
Borne-Bauman, CandiceOperational/managerial controlIndividual01/01/2019
Fernandes, TarynOperational/managerial controlIndividual03/01/2025
Flueckiger, RussellOperational/managerial controlIndividual05/01/2015
Lehman, ScottOperational/managerial controlIndividual07/14/2020
Macklin, LarryOperational/managerial controlIndividual05/01/2015
McIntire, DavidOperational/managerial controlIndividual01/01/2019
Moore, LeslieOperational/managerial controlIndividual04/14/2025
Smith, ScottOperational/managerial controlIndividual01/01/2020
Sprunger, KyleOperational/managerial controlIndividual01/01/2018
Wheeler, DaneOperational/managerial controlIndividual05/01/2012
Greatorex, TinaIndividual is an owner, partner or trustee of any ADP of the SNFIndividual01/08/2026
Schiowitz, MarcIndividual is an owner, partner or trustee of any ADP of the SNFIndividual01/08/2026
Sebbag, GabrielIndividual is an owner, partner or trustee of any ADP of the SNFIndividual01/08/2026
343 Nappanee Propco LLCAdp of the SNFOrganization11/01/2020
Advanced Care Consultants LLCAdp of the SNFOrganization09/01/2022
Blue Management Services LLCAdp of the SNFOrganization01/01/2024
Clinical Consulting Services LLCAdp of the SNFOrganization11/01/2020
First Bank of BerneAdp of the SNFOrganization01/01/2020
Lme Family Holdings LLCAdp of the SNFOrganization11/01/2020
Samara Family Holdings LLCAdp of the SNFOrganization11/01/2020
Summation Financial Services LLCAdp of the SNFOrganization11/01/2020
Woodland Nursing and Rehab LLCAdp of the SNFOrganization11/01/2020
Fernandes, TarynAdp of the SNFIndividual03/01/2025
Moore, LeslieAdp of the SNFIndividual04/14/2025

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 15 problems in this area, most recently on November 21, 2025: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
  2. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 10 problems in this area, most recently on November 21, 2025: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident."
  3. How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 5 problems in this area, most recently on November 21, 2025: "Ensure each resident’s drug regimen must be free from unnecessary drugs."
  4. What changed in infection control since the last inspection, and who on staff is the infection preventionist?Inspectors cited 5 problems in this area, most recently on November 21, 2025: "Provide and implement an infection prevention and control program."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.13 hours per resident per day, below the Indiana average of 3.25.

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Common questions

What is Woodland Manor's Medicare star rating?
CMS rates Woodland Manor 1 out of 5 stars overall, with 1 for health inspections, 1 for staffing and 1 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Woodland Manor get at its last inspection?
9 health deficiencies at the standard inspection on November 21, 2025. The Indiana average is 7.2.
Has Woodland Manor been fined?
Yes. CMS lists 2 fines totaling $114,339 in the last three years.
Does Woodland Manor accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Woodland Manor?
CMS lists 32 owners and managers, and links the home to Adams County Memorial Hospital. Legal business name: ADAMS COUNTY MEMORIAL HOSPITAL.

Sources

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