Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 0
Jul 8, 2025
Visit Reason
This visit was conducted for the Investigation of Complaint IN00462082.
Findings
No deficiencies related to the complaint allegations were cited. Woodland Manor was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00462082 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 74
Total Capacity: 74
Medicaid Census: 58
Other Payor Census: 16
Inspection Report
Re-Inspection
Census: 74
Capacity: 80
Deficiencies: 0
Jul 2, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey that exited on 05/29/2025 was conducted by the Indiana Department of Health.
Findings
At this PSR, Woodland Manor was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Life Safety
Census: 70
Capacity: 80
Deficiencies: 7
May 29, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code (LSC) Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 05/29/2025.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included failure to maintain battery-operated smoke alarms, improper placement of kitchen cooking appliances under fire suppression hood, incorrect fire alarm system time, lack of ground fault circuit interrupter (GFCI) protection on electrical receptacles, failure to conduct annual fire door inspections, failure to test non-hospital-grade electrical receptacles annually, and failure to maintain documentation and testing of Patient Care Related Electrical Equipment (PCREE).
Severity Breakdown
SS=F: 4
SS=E: 2
SS=C: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure battery-operated smoke alarms were maintained and tested weekly as per manufacturer's instructions. | SS=F |
| Failed to provide an approved method for returning cooking appliances to approved design location under kitchen hood extinguishing system. | SS=E |
| Failed to ensure fire alarm system was continuously in proper operating condition; fire control panel time was incorrect. | SS=C |
| Failed to ensure 2 electrical receptacles were provided with ground fault circuit interrupter (GFCI) protection against electric shock. | SS=E |
| Failed to ensure annual inspection and testing of fire door assemblies were completed and documented. | SS=F |
| Failed to ensure all non-hospital-grade electrical receptacles at resident room locations were tested at least annually. | SS=F |
| Failed to conduct required maintenance and maintain documentation of inspections for Patient Care Related Electrical Equipment (PCREE). | SS=F |
Report Facts
Certified beds: 80
Census: 70
Deficiencies cited: 7
Completion dates: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stacy Cromer | QAA | Signed report as Laboratory Director or Provider/Supplier Representative |
| Maintenance Director | Named in multiple findings related to smoke alarm testing, fire alarm system, electrical receptacles, fire door inspections, and PCREE testing | |
| Administrator | Involved in discussions and exit conference regarding deficiencies and corrective actions | |
| Senior Maintenance Director | Involved in discussions and exit conference regarding deficiencies and corrective actions | |
| Quality Assurance Administrator | Involved in discussions and exit conference regarding deficiencies and corrective actions |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 70
Deficiencies: 0
May 27, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00459695 and IN00459369.
Findings
No deficiencies related to the allegations in complaints IN00459695 and IN00459369 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaints IN00459695 and IN00459369 found no deficiencies related to the allegations.
Report Facts
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 52
Census Payor Type - Other: 13
Inspection Report
Renewal
Census: 69
Capacity: 69
Deficiencies: 7
May 5, 2025
Visit Reason
This visit was for a Recertification and State Licensure survey conducted in conjunction with a Post Survey Revisit related to a prior complaint investigation.
Findings
The facility was found deficient in multiple areas including failure to provide mail delivery on Saturdays, failure to provide proper notice prior to involuntary discharge, failure to provide showers per resident preference, failure to notify physician of abnormal blood sugars, improper storage of respiratory equipment, failure to attempt gradual dose reduction of psychotropic medications, and medication storage issues including unlabeled and loose medications.
Complaint Details
This survey was conducted in conjunction with a Post Survey Revisit to the Investigation of Complaint IN00453447 completed on February 28, 2025.
Severity Breakdown
SS=C: 1
SS=D: 6
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to provide mail delivery on Saturdays affecting 10 residents. | SS=C |
| Failed to ensure proper notice prior to involuntary discharge for 1 of 4 residents reviewed. | SS=D |
| Failed to provide showers as per resident preference for 1 of 7 residents reviewed for ADL care. | SS=D |
| Failed to notify physician of abnormal blood sugars for 1 of 1 resident reviewed for insulin usage. | SS=D |
| Failed to store respiratory equipment in a sanitary manner for 2 of 3 residents reviewed. | SS=D |
| Failed to attempt gradual dose reduction of antipsychotic medication for 1 of 5 residents reviewed. | SS=D |
| Failed to ensure medication storage areas were clean, free from loose medications, and medications were labeled and dated when opened in 2 medication carts. | SS=D |
Report Facts
Census: 69
Total Capacity: 69
Residents affected by mail delivery deficiency: 10
Residents reviewed for ADL care: 7
Residents reviewed for involuntary discharge notice: 4
Residents reviewed for insulin usage: 1
Residents reviewed for respiratory care: 3
Residents reviewed for psychotropic medication: 5
Medication carts reviewed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident 271 | Resident who delivered mail during the week but not on Saturdays | |
| Business Office Manager | Interviewed regarding mail delivery process and staff responsibilities | |
| Director of Nursing | Director of Nursing | Interviewed regarding shower documentation and care |
| Quality Assurance Administrator | Quality Assurance Administrator | Provided policies and interviewed regarding multiple deficiencies including mail delivery, discharge notice, bathing, blood sugar notification, respiratory care, and medication storage |
| LPN 2 | Licensed Practical Nurse | Observed medication storage and respiratory equipment issues |
| LPN 7 | Licensed Practical Nurse | Observed medication storage issues |
| Social Service Assistant | Interviewed regarding psychotropic medication gradual dose reduction |
Inspection Report
Renewal
Deficiencies: 0
May 5, 2025
Visit Reason
Paper Compliance to the Recertification and State Licensure Survey completed on May 5, 2025.
Findings
Woodland Manor was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2, in regard to the Paper Compliance Review to the Recertification and State Licensure Survey.
Inspection Report
Re-Inspection
Census: 69
Capacity: 69
Deficiencies: 0
May 5, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the PSR completed on 2025-04-11 related to the Investigation of Complaint IN00453447 completed on 2025-02-28. The visit was conducted in conjunction with the Annual Recertification and State Licensure survey.
Findings
Woodland Manor was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Investigation of Complaint IN00453447. The complaint was corrected.
Complaint Details
Complaint IN00453447 was investigated and found corrected during this visit.
Report Facts
Census SNF/NF beds: 69
Census total residents: 69
Census Medicare residents: 3
Census Medicaid residents: 47
Census other payor residents: 19
Inspection Report
Re-Inspection
Census: 66
Capacity: 66
Deficiencies: 2
Apr 10, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00453447, IN00453989, and IN00452803 completed on 2025-02-28. The revisit was conducted to verify correction of cited deficiencies and to assess unrelated deficiencies.
Findings
The facility failed to prevent the development of an unstageable pressure ulcer in one resident at mild risk for pressure ulcers and failed to follow infection control guidelines during incontinence care for another resident. The facility did not implement systemic plans of correction to prevent recurrence of these deficiencies. Some complaints were corrected while one remained uncorrected.
Complaint Details
Complaint IN00453447 was not corrected. Complaints IN00453989 and IN00452803 were corrected.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure a resident at mild risk for pressure ulcers did not develop an unstageable pressure ulcer. | SS=D |
| Failure to ensure staff followed infection control guidelines when completing perineal care for a resident. | SS=D |
Report Facts
Census: 66
Total Capacity: 66
Medicare Census: 2
Medicaid Census: 63
Other Payor Census: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stacy Cromer | QAA | Signed the report as Laboratory Director or Provider/Supplier Representative |
| CNA 4 | Named in infection control deficiency related to peri-care | |
| ADON | Assistant Director of Nursing | Interviewed regarding pressure ulcer staging and wound observations |
| DON | Director of Nursing | Responsible for corrective actions and education related to pressure ulcer prevention and infection control |
| Wound Nurse Practitioner | Provided wound assessment and staging for Resident W | |
| Administrator | Provided facility policies during interviews |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 5
Feb 27, 2025
Visit Reason
Investigation of multiple complaints (IN00453989, IN00452803, IN00448083, IN00453447) regarding resident care, abuse, neglect, pressure ulcers, staffing, and infection control at Woodland Manor.
Findings
The facility was found deficient in timely response to call lights affecting resident dignity, neglect and abuse including inadequate incontinent care and supervision, failure to prevent and identify pressure ulcers, insufficient staffing levels leading to delayed care, and failure to follow infection control procedures for residents on Enhanced Barrier Precautions.
Complaint Details
Complaints IN00453989, IN00452803, IN00453447 had substantiated federal deficiencies related to call light response, abuse and neglect, and pressure ulcer care. Complaint IN00448083 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 2
SS=G: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure a resident's call light was answered timely and care was provided to maintain dignity (Resident H). | SS=D |
| Failure to ensure residents were free from neglect and abuse, including extensive incontinence without care and inadequate supervision (Residents T, P, Q). | SS=G |
| Failure to prevent and identify pressure injuries resulting in Stage 3 and unstageable wounds (Residents E and F). | SS=G |
| Failure to ensure sufficient nursing staff to provide timely care and prevent staff from working more than 16 hours per day. | SS=G |
| Failure to follow infection control procedures for a resident on Enhanced Barrier Precautions (Resident M). | SS=D |
Report Facts
Census: 68
Staff to resident ratio: 1
Number of residents on Unit 1 and 2: 39
Call light audits: 4
Incontinence checks audits: 4
Monitoring duration: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chris Chalman | Administrator | Named in plan of correction and dispute resolution statements |
| LPN 6 | Charge nurse involved in call light and abuse findings, worked over 20 hours on 2/27/2025 | |
| QMA 3 | Staff involved in call light and abuse findings, worked over 20 hours on 2/27/2025 | |
| Director of Quality Assurance | Provided interviews and policies related to deficiencies |
Inspection Report
Re-Inspection
Census: 69
Capacity: 80
Deficiencies: 0
Feb 17, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey that exited on 12/23/24 by the Indiana Department of Health.
Findings
At this PSR survey, Woodland Manor was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.73, and with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Report Facts
Certified beds: 80
Census: 69
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 3, 2025
Visit Reason
Paper Compliance Review to the Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and Investigation of Complaints IN00388683, IN00394202, IN00394334, IN00394560 and IN00404072.
Findings
Woodland Manor was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 in regard to the Paper Compliance Review to the Post Survey Revisit to the Recertification and State Licensure Survey and Complaint Investigation.
Complaint Details
Investigation of multiple complaints identified by numbers IN00388683, IN00394202, IN00394334, IN00394560 and IN00404072.
Inspection Report
Re-Inspection
Census: 69
Deficiencies: 8
Dec 27, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 11/14/2024, including a PSR to the Investigation of Complaints IN00442899, IN00446004 and IN00442666.
Findings
The facility was found deficient in multiple areas including failure to timely notify physicians of changes in condition, failure to provide showers as scheduled, failure to follow dietary recommendations, failure to prevent accidents related to hot liquids, failure to ensure availability of physician-ordered medications, failure to follow infection control practices during catheter care, and failure to provide consented influenza and COVID-19 vaccinations.
Complaint Details
This visit included a Post Survey Revisit to the Investigation of Complaints IN00442899, IN00446004 and IN00442666. Complaint IN00442666 was corrected, Complaint IN00446004 was not corrected, and Complaint IN00442899 was corrected.
Severity Breakdown
SS=E: 1
SS=D: 7
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to notify the physician timely of a change in condition related to a burn injury for Resident L. | SS=E |
| Failed to ensure showers were provided for 4 of 7 residents reviewed for ADLs. | SS=D |
| Failed to follow dietary recommendations for 1 of 3 residents reviewed for quality of care. | SS=D |
| Failed to ensure adequate assistance was provided to prevent hot soup spillage for 1 of 3 residents reviewed for accidents. | SS=D |
| Failed to ensure physician ordered medications were available for 5 of 6 residents whose medications were reviewed. | SS=D |
| Failed to ensure infection control practices were followed related to glove use and handwashing during perineal and catheter care for 2 of 2 residents observed. | SS=D |
| Failed to provide consented influenza vaccination for 1 of 4 residents reviewed. | SS=D |
| Failed to provide consented COVID-19 vaccination for 1 of 4 residents reviewed. | SS=D |
Report Facts
Census: 69
Medicare residents: 2
Medicaid residents: 66
Other residents: 1
Deficiencies cited: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chris Chalman | Interim Administrator | Signed report |
| LPN 2 | Involved in failure to timely assess and notify physician of Resident L's burn injury | |
| DON | Director of Nursing | Named in multiple findings including burn injury assessment, medication availability, infection control, and vaccination administration |
| CNA 6 | Observed during infection control deficiency | |
| QMA 4 | Observed during infection control deficiency |
Inspection Report
Life Safety
Census: 69
Capacity: 80
Deficiencies: 19
Dec 23, 2024
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health to assess compliance with emergency preparedness requirements and life safety codes.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code standards. Deficiencies included failure to annually review and update the Emergency Preparedness Plan and related policies, lack of tracking systems for staff and residents during emergencies, incomplete emergency communication plans, inadequate emergency preparedness training and testing, failure to conduct required fire drills on all shifts, and life safety issues such as malfunctioning self-closing doors, missing semiannual inspections of kitchen fire suppression and exhaust systems, and overdue maintenance of portable fire extinguishers.
Severity Breakdown
SS=F: 12
SS=E: 6
Deficiencies (19)
| Description | Severity |
|---|---|
| Failed to review and update the Emergency Preparedness Plan (EPP) at least annually. | SS=F |
| Emergency Preparedness Plan failed to address resident population and continuity of operations. | SS=F |
| Failed to review and update Emergency Preparedness Policies and Procedures annually. | SS=F |
| Failed to include system to track location of on-duty staff and sheltered residents during and after an emergency. | SS=F |
| Failed to review and update Emergency Preparedness Communication Plan annually. | SS=F |
| Emergency Preparedness Communication Plan failed to address primary and alternate means of communication. | SS=F |
| Failed to include method for sharing emergency plan information with residents and families. | SS=F |
| Failed to review and update Emergency Preparedness Training and Testing Program annually. | SS=F |
| Failed to conduct annual training for Emergency Preparedness Program and demonstrate staff knowledge. | SS=F |
| Failed to conduct required emergency preparedness exercises including full-scale and additional drills. | SS=F |
| Central Supply Storage room door failed to fully close and latch. | SS=E |
| Kitchen fire suppression system was not inspected semiannually. | SS=E |
| Kitchen exhaust system was not inspected semiannually. | SS=E |
| Portable fire extinguisher in maintenance office was not inspected within the last year. | SS=E |
| Resident room corridor door did not close and latch properly. | SS=E |
| Smoke barrier doors failed to restrict smoke movement properly. | SS=E |
| Public restroom doors did not close completely due to malfunctioning door coordinator. | SS=E |
| Failed to conduct quarterly fire drills on each shift. | SS=F |
| Flexible cords and adapters were used as substitutes for fixed wiring in patient care areas. | SS=E |
Report Facts
Certified beds: 80
Census: 69
Deficiencies cited: 18
Fire extinguisher inspection date: Mar 26, 2024
Kitchen fire suppression inspection date: Apr 16, 2024
Kitchen exhaust system inspection date: Feb 14, 2024
Fire drill date: Dec 28, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chris Chalman | Interim Administrator | Named in exit conference and review of findings |
| Maintenance Director | Interviewed regarding deficiencies and corrective actions |
Inspection Report
Recertification
Census: 68
Capacity: 68
Deficiencies: 19
Nov 14, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of multiple complaints.
Findings
The facility was found deficient in multiple areas including failure to notify physicians timely of changes, incomplete transfer and discharge documentation, inadequate care plans, failure to provide showers as scheduled, medication administration errors, unsanitary pantry conditions, environmental maintenance issues, pest control deficiencies, infection control lapses, and incomplete employee training.
Complaint Details
This survey included investigations of complaints IN00442666, IN00442686, IN00442899, IN00446004, IN00446365, and IN00446377. Several complaints were substantiated with federal deficiencies cited.
Severity Breakdown
SS=E: 7
SS=D: 6
SS=F: 3
Deficiencies (19)
| Description | Severity |
|---|---|
| Failed to notify physician timely of changes for blood glucose readings outside ordered parameters and other condition changes for multiple residents. | SS=E |
| Failed to ensure pertinent transfer and resident clinical information was completed for hospital transfers for Resident B. | SS=D |
| Failed to provide transfer/discharge forms for 4 residents transferred to hospital and failed to notify Ombudsman. | SS=E |
| Failed to provide bed hold forms for 4 residents transferred to hospital. | SS=E |
| Failed to develop comprehensive person-centered care plans for activities and medication use for 2 residents. | SS=D |
| Failed to ensure showers were provided as scheduled for 3 residents. | SS=D |
| Failed to ensure residents were provided activities meeting their interests and needs. | SS=D |
| Failed to discontinue physician ordered additional fluids timely resulting in edema for Resident M. | SS=D |
| Failed to ensure appropriate follow-up care for impaired vision for Resident 35. | SS=D |
| Failed to maintain a safe environment to prevent burns related to a melted PTAC unit and failed to implement interventions for Resident 12 to prevent burns from hot liquids. | SS=E |
| Failed to ensure physician ordered medications were available for administration for 3 residents. | SS=D |
| Failed to adequately label over the counter medications and maintain proper medication refrigerator temperatures. | SS=E |
| Failed to maintain sanitary conditions in the 400 unit pantry including dirty microwave and stained blanket. | SS=E |
| Failed to maintain a sanitary environment related to urine odors, dirty ceilings and walls, unpainted spackle, and gouges on walls. | SS=F |
| Failed to maintain an effective pest control program related to fruit fly infestation throughout the facility. | SS=F |
| Failed to ensure employees completed yearly education and training on residents' rights, dementia, and abuse for 4 employees. | — |
| Failed to screen employees for tuberculosis within one month prior to employment and annually thereafter for 10 employees. | — |
| Failed to ensure infection control practices related to glove use and handwashing during perineal and catheter care. | SS=D |
| Failed to provide pneumococcal vaccination timely for Resident 11. | SS=D |
Report Facts
Residents on census: 68
Total licensed capacity: 68
Survey dates: 2024-11-07 to 2024-11-14
Deficiency counts: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nursing Assistant | Named in relation to missing annual training on resident rights, dementia, and abuse |
| Dietary Assistant 5 | Dietary Assistant | Named in relation to missing annual training on resident rights, dementia, and abuse |
| Cook 7 | Cook | Named in relation to missing annual training on resident rights, dementia, and abuse |
| LPN 11 | Licensed Practical Nurse | Named in relation to missing annual training on resident rights, dementia, and abuse |
| CNA 23 | Certified Nursing Assistant | Named in relation to infection control deficiency during catheter care |
| LPN 19 | Licensed Practical Nurse | Named in relation to infection control deficiency during catheter care |
| Director of Nursing | Director of Nursing | Named in relation to multiple findings including infection control, medication administration, and care plan deficiencies |
| Executive Director | Executive Director | Named in relation to environmental and maintenance deficiencies |
| Maintenance Director | Maintenance Director | Named in relation to environmental and maintenance deficiencies |
| Director of Housekeeping | Director of Housekeeping | Named in relation to environmental and sanitation deficiencies |
| Social Services Director | Social Services Director | Named in relation to care plan and vision services deficiencies |
| Activities Director | Activities Director | Named in relation to care plan and activity program deficiencies |
| Quality Assurance Administrator | Quality Assurance Administrator | Named in relation to multiple findings and policy provision |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 7, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaints IN00442414 completed on September 6, 2024.
Findings
Woodland Manor was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
The visit was related to complaint investigation IN00442414, and the facility was found to be in compliance.
Inspection Report
Complaint Investigation
Census: 67
Capacity: 67
Deficiencies: 1
Sep 6, 2024
Visit Reason
This visit was conducted for the investigation of four complaints (IN00442414, IN00441939, IN00441580, and IN00441211) regarding the facility's compliance with federal and state regulations.
Findings
The facility was found deficient related to Complaint IN00442414 for failing to ensure that a resident requiring dialysis received proper assessment and monitoring for complications before and after dialysis treatments. No deficiencies were found related to the other three complaints.
Complaint Details
Complaint IN00442414 was substantiated with federal/state deficiencies cited at F698. Complaints IN00441939, IN00441580, and IN00441211 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 1 residents who required dialysis received assessment/monitoring for complications prior to and/or after dialysis treatments according to facility policy and resident's plan of care. | SS=D |
Report Facts
Census: 67
Total Capacity: 67
Medicare Census: 3
Medicaid Census: 57
Other Payor Census: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katherine Wright | Administrator | Signed report as provider/supplier representative |
| Director of Nursing | Interviewed regarding failure to assess dialysis fistula post-treatment |
Inspection Report
Re-Inspection
Census: 65
Capacity: 65
Deficiencies: 0
Aug 13, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00436291 completed on 2024-06-21.
Findings
Woodland Manor was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaint IN00436291.
Complaint Details
Complaint IN00436291 was corrected.
Report Facts
Census SNF/NF beds: 65
Census Medicare residents: 5
Census Medicaid residents: 60
Inspection Report
Re-Inspection
Census: 69
Capacity: 80
Deficiencies: 0
Jul 30, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted for the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey following the initial surveys that exited on 06/11/24.
Findings
At this Emergency Preparedness PSR, Woodland Manor was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. At the Life Safety Code PSR, Woodland Manor was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Report Facts
Certified beds: 80
Census: 69
Inspection Report
Re-Inspection
Census: 67
Capacity: 67
Deficiencies: 0
Jul 9, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on May 17, 2024, including a PSR to the Investigation of Complaints IN00434221 and IN00434242.
Findings
Woodland Manor was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Recertification and State Licensure Survey and the PSR to the Investigation of Complaints IN00434221 and IN00434242.
Complaint Details
Complaints IN00434221 and IN00434242 were investigated and found to be corrected.
Report Facts
Census: 67
Total Capacity: 67
Medicare Census: 2
Medicaid Census: 47
Other Payor Census: 18
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 8, 2024
Visit Reason
Paper Compliance to the Investigation of Complaints IN00436526 completed on June 14, 2024.
Findings
Woodland Manor was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Paper Compliance Review to the complaint investigation.
Complaint Details
Investigation of Complaints IN00436526 completed on June 14, 2024; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 69
Capacity: 69
Deficiencies: 0
Jul 3, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00437442, IN00437469, and IN00437373 at Woodland Manor.
Findings
No deficiencies related to the allegations in complaints IN00437442, IN00437469, and IN00437373 were cited. Woodland Manor was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaints IN00437442, IN00437469, and IN00437373 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 69
Total Capacity: 69
Census Payor Type Medicare: 2
Census Payor Type Medicaid: 49
Census Payor Type Other: 18
Inspection Report
Complaint Investigation
Census: 69
Capacity: 69
Deficiencies: 1
Jun 21, 2024
Visit Reason
This visit was for the investigation of Complaints IN00436905 and IN00436291. Complaint IN00436905 had no deficiencies related to the allegations, while Complaint IN00436291 resulted in federal/state deficiencies cited at F689.
Findings
The facility failed to ensure the Memory Care Unit was free from incontinence brief debris and failed to provide adequate supervision to a cognitively impaired resident, resulting in Resident C experiencing a blocked airway, a change in level of consciousness, and requiring emergent EMS treatment. Resident C subsequently became pulseless and non-responsive during EMT care.
Complaint Details
Complaint IN00436291 was substantiated with federal/state deficiencies cited. Complaint IN00436905 had no deficiencies related to the allegations.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure the Memory Care Unit was free from incontinence brief debris and failed to provide adequate supervision to prevent ingestion of debris by a cognitively impaired resident. | SS=G |
Report Facts
Census: 69
Total Capacity: 69
Staffing hours: 8
Audit shifts: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 3 | Registered Nurse | Worked evening shift on Memory Care unit on 6/8/24; involved in care of Resident C during incident |
| CNA 2 | Certified Nursing Assistant | Scheduled to work evening and night shifts on 6/8/24; called off but came in to help; left at 10:15 P.M. leaving RN 3 alone |
| LPN 4 | Licensed Practical Nurse | Assisted RN 3 by performing mouth sweeps on Resident C during emergency |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 67
Deficiencies: 1
Jun 14, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00436483, IN00436526, and IN00435617. The investigation focused on allegations related to resident supervision and elopement.
Findings
The facility failed to ensure adequate supervision and adherence to elopement policy for a resident with traumatic brain injury who eloped from a physician's office appointment. The resident was missing for several days before being found. The facility implemented corrective actions including visual checks, wander guard placement, updated care plans, and staff training on elopement prevention.
Complaint Details
Complaint IN00436483 - No deficiencies related to the allegations were cited. Complaint IN00436526 - Federal/State deficiency related to the allegations cited at F689. Complaint IN00435617 - No deficiencies related to the allegations were cited.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident received adequate supervision and the facility's elopement policy was followed for a resident with traumatic brain injury who eloped from a physician's office appointment. | SS=D |
Report Facts
Census: 67
Total Capacity: 67
Distance traveled by resident during elopement (miles): 4.5
Date of survey completion: Jun 14, 2024
Date of plan of correction completion: Jul 5, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Provided information about resident's travel distance and supervision after elopement |
| Administrator | Administrator | Provided the facility's elopement policy and details about the investigation |
Inspection Report
Routine
Census: 67
Capacity: 80
Deficiencies: 15
Jun 11, 2024
Visit Reason
Routine Emergency Preparedness and Life Safety Code survey conducted by the Indiana Department of Health to assess compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with emergency preparedness requirements including lack of tracking system for staff and residents during emergencies, incomplete communication plans, failure to conduct required emergency preparedness exercises, and multiple life safety code deficiencies including egress door locking issues, obstructed exit discharge, incomplete fire watch and sprinkler system policies, missing fire door inspections, incomplete fire drills, and unsafe electrical and fire safety practices.
Severity Breakdown
SS=F: 6
SS=E: 5
SS=D: 3
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to ensure emergency preparedness policies include a system to track location of on-duty staff and sheltered residents during and after an emergency. | SS=F |
| Failed to ensure emergency preparedness communication plan includes primary and alternate means for communicating with staff and emergency management agencies. | SS=F |
| Failed to conduct emergency preparedness exercises at least twice per year including unannounced staff drills. | SS=F |
| Failed to ensure means of egress doors were readily accessible and did not require a tool or key for exit; exit door codes were not posted or known by staff. | SS=E |
| Failed to maintain exit discharge free of obstructions; plastic chairs blocked emergency exit discharge. | SS=E |
| Failed to provide complete fire watch policy for fire alarm system out of service more than 4 hours. | SS=F |
| Failed to maintain ceiling construction around sprinkler head causing gap and potential smoke passage. | SS=E |
| Failed to provide complete fire watch policy for sprinkler system impairment out of service more than 10 hours. | SS=F |
| Failed to inspect monthly the kitchen K-class fire extinguisher. | SS=D |
| Failed to ensure corridor doors resist passage of smoke due to door penetrations and propped open kitchen corridor door. | SS=E |
| Failed to provide proper electrical outlet cover plate in resident room 405. | SS=D |
| Failed to ensure annual inspection and testing of oxygen room fire door assembly and rolling fire door between kitchen and dining area. | SS=E |
| Failed to ensure portable space heaters were not used in the facility. | SS=E |
| Failed to prevent use of daisy chained power strips as substitute for fixed wiring. | SS=D |
| Failed to conduct quarterly fire drills on each shift and failed to verify transmission of fire alarm signal during night shift fire drills. | SS=F |
Report Facts
Certified beds: 80
Census: 67
Deficiency count: 14
Fire drills missing: 6
Fire drills conducted: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katherine Wright | Administrator | Named in relation to emergency preparedness and life safety findings |
Inspection Report
Annual Inspection
Census: 67
Capacity: 67
Deficiencies: 11
May 17, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey including investigation of Complaints IN00434221 and IN00434242, resulting in an Immediate Jeopardy.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, care planning, ADL care, catheter care, bedrail assessments, nurse staffing postings, pharmacy narcotic counts, food safety and sanitation, infection control including glucometer sanitation, and pest control. Immediate jeopardy related to infection control was removed after corrective actions.
Complaint Details
Complaints IN00434221 and IN00434242 were investigated. The visit resulted in an Immediate Jeopardy related to infection control practices, which was removed after corrective actions on 5/17/2024.
Severity Breakdown
SS=D: 7
SS=E: 2
SS=K: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Staff failed to treat residents with dignity and respect, including inappropriate communication and failure to provide dignity covers for Foley catheter bags. | SS=D |
| Failure to develop person-centered care plans for behaviors for residents on psychotropic medications. | SS=D |
| Failure to hold care plan meetings with residents/representatives after each MDS assessment. | SS=D |
| Failure to provide showers at least twice weekly for dependent residents. | SS=D |
| Failure to ensure urinary catheter drainage bags were kept off the floor to prevent infection. | SS=D |
| Failure to assess residents for bedrail use prior to maintaining bedrails in the upright position. | SS=D |
| Failure to post daily nursing staffing data at the beginning of each shift. | SS=D |
| Failure to maintain accurate narcotic counts and documentation every shift. | SS=D |
| Failure to ensure food was stored, prepared, served and delivered in a sanitary manner, including undated food items, dirty kitchen surfaces, and improper food handling. | SS=E |
| Failure to provide nursing services in a safe and sanitary manner to prevent transmission of communicable diseases and infections, including failure to sanitize glucometers between uses, improper catheter bag placement, improper ice chest use, poor hand hygiene, and improper respiratory equipment storage. | SS=K |
| Failure to maintain an effective pest control program related to gnats in resident rooms and common areas. | SS=E |
Report Facts
Residents present: 67
Total licensed capacity: 67
Narcotic count log missing signatures: 30
Residents reviewed for ADL care: 5
Residents reviewed for catheter care: 3
Residents reviewed for nursing care: 3
Residents with bloodborne pathogens: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katherine Wright | Administrator | Signed report and involved in complaint reporting |
| LPN 2 | Observed providing skin treatment and educated on hand hygiene | |
| QMA 2 | Observed not sanitizing glucometer between uses and was in-serviced | |
| CNA 8 | Observed poor glove use and hand hygiene during perineal care | |
| RN 13 | Observed not intervening when resident accessed ice cooler improperly | |
| Cook 16 | Observed kitchen sanitation issues and undated food | |
| Director of Nursing | Director of Nursing | Provided multiple policies and interviews regarding care and infection control |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 70
Deficiencies: 0
Apr 3, 2024
Visit Reason
This visit was conducted for the Investigation of Complaint IN00430397 and was in conjunction with a Post Survey Revisit to the Investigation of Complaint IN00428613 completed on March 6, 2024.
Findings
No deficiencies related to Complaint IN00430397 were cited. Complaint IN00428613 was corrected. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Investigation of Complaint IN00430397 found no deficiencies related to the allegations. Complaint IN00428613 was corrected as of the prior survey.
Report Facts
Census: 70
Total Capacity: 70
Medicare Census: 1
Medicaid Census: 63
Other Payor Census: 6
Inspection Report
Re-Inspection
Census: 70
Capacity: 70
Deficiencies: 0
Apr 2, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00428613 completed on March 6, 2024, and was conducted in conjunction with the Investigation of Complaint IN00430397.
Findings
Woodland Manor was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Investigation of Complaint IN00428613. Complaint IN00428613 was corrected, and no deficiencies related to Complaint IN00430397 were cited.
Complaint Details
Complaint IN00428613 was corrected. Complaint IN00430397 had no deficiencies related to the allegations cited.
Report Facts
Census SNF/NF: 70
Total Capacity: 70
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 63
Census Payor Type - Other: 6
Inspection Report
Complaint Investigation
Census: 67
Capacity: 67
Deficiencies: 1
Mar 6, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00428613 regarding allegations of resident-to-resident sexual abuse at the facility.
Findings
The facility failed to ensure Resident C was free from sexual abuse by Resident B. Resident B was observed touching Resident C inappropriately while she was asleep. The facility responded immediately by placing Resident B on 1:1 observation and facilitating his discharge to a behavioral health facility. Resident C showed no negative psychological effects from the incident.
Complaint Details
Complaint IN00428613 was substantiated with federal/state deficiencies cited at F600 related to abuse. The facility failed to prevent sexual abuse by Resident B against Resident C. Resident B had a history of hypersexual behaviors documented prior to admission. The facility implemented 1:1 observation and discharged Resident B to a behavioral health facility. Resident C did not recall the incident and showed no negative psychological or physical effects.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure Resident C was free from resident-to-resident sexual abuse by Resident B. | SS=G |
Report Facts
Census: 67
Total Capacity: 67
Medicare Census: 5
Medicaid Census: 61
Other Payor Census: 1
Deficiency Completion Date: Mar 28, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katherine Wright | Administrator | Signed plan of correction and submitted facility response |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 67
Deficiencies: 0
Feb 7, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00427634, IN00426780, and IN00425706.
Findings
No deficiencies related to the allegations in complaints IN00427634, IN00426780, and IN00425706 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaints IN00427634, IN00426780, and IN00425706 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 67
Total census: 67
Medicare census: 2
Medicaid census: 61
Other payor census: 4
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 30, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaints IN00422875 completed on December 21, 2023.
Findings
Woodland Manor was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
The visit was related to complaint investigation IN00422875, and the facility was found to be in compliance.
Inspection Report
Complaint Investigation
Census: 69
Capacity: 69
Deficiencies: 2
Dec 18, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00422734, IN00422875, and IN00424443 at Woodland Manor nursing facility.
Findings
The investigation found no deficiencies related to complaints IN00422734 and IN00424443. However, federal and state deficiencies were cited related to complaint IN00422875, specifically regarding failure to notify responsible parties of resident transfers and failure to provide correct clinical information to receiving hospitals.
Complaint Details
Complaint IN00422734 had no deficiencies related to the allegations. Complaint IN00422875 had federal/state deficiencies cited at F580 and F622 related to failure to notify responsible party of hospital transfer and failure to provide correct clinical information to receiving hospital. Complaint IN00424443 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to notify the responsible party of a transfer to the Emergency Room for 1 of 3 residents reviewed (Resident D). | SS=D |
| Failure to ensure the correct clinical information was provided to a receiving hospital necessary to meet a resident's needs and ongoing care (Resident D). | SS=D |
Report Facts
Census: 69
Total Capacity: 69
Medicare Census: 3
Medicaid Census: 61
Other Payor Census: 5
Inspection Report
Complaint Investigation
Census: 69
Capacity: 69
Deficiencies: 0
Nov 9, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00419022.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00419022 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 2
Medicaid census: 60
Other payor census: 5
Private pay census: 2
Inspection Report
Complaint Investigation
Census: 71
Capacity: 71
Deficiencies: 0
Sep 19, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00417631 and IN00416739, in conjunction with a previous PSR investigation of complaints IN00414158 and IN00408204.
Findings
No deficiencies related to the allegations in complaints IN00417631 and IN00416739 were cited. Complaints IN00414158 and IN00408204 were corrected. The facility was found to be in compliance with relevant federal and state regulations.
Complaint Details
Investigation of Complaints IN00417631 and IN00416739 found no deficiencies related to the allegations. Complaints IN00414158 and IN00408204 were corrected.
Report Facts
Census Bed Type: 71
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 63
Census Payor Type - Other: 7
Inspection Report
Re-Inspection
Census: 71
Capacity: 71
Deficiencies: 0
Sep 19, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00414158 and IN00408204 completed on 2023-08-09, conducted in conjunction with the Investigation of Complaints IN00417631 and IN00416739.
Findings
The facility was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Investigation of Complaints IN00414158 and IN00408204. Complaints IN00414158 and IN00408204 were corrected, and no deficiencies related to allegations were cited for complaints IN00417631 and IN00416739.
Complaint Details
Complaint IN00414158 - Corrected. Complaint IN00408204 - Corrected. Complaint IN00417631 - No deficiencies related to the allegations are cited. Complaint IN00416739 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type: 71
Total Capacity: 71
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 63
Census Payor Type - Other: 7
Inspection Report
Complaint Investigation
Census: 67
Capacity: 67
Deficiencies: 2
Aug 9, 2023
Visit Reason
This visit was for the investigation of multiple complaints (IN00414158, IN00411541, IN00409930, IN00408204, IN00407753, and IN00406416) regarding alleged deficiencies at Woodland Manor.
Findings
The facility failed to prevent misappropriation of narcotics for 3 of 4 residents reviewed, with incomplete and inaccurate documentation of narcotic medications. Several medication errors and missing Controlled Drug Records (CDRs) were identified. Corrective actions including audits, education, and policy reviews were implemented.
Complaint Details
Complaints IN00414158 and IN00408204 had Federal/State deficiencies related to allegations cited at F602. Other complaints had no deficiencies related to allegations.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to prevent misappropriation of narcotics for 3 of 4 residents reviewed (Resident G, Resident F, Resident K). | SS=D |
| Failed to establish and maintain a system that accounted for, periodically reconciled, and ensured disposition of all controlled drugs related to incomplete and inaccurate documentation of narcotic medications. | SS=D |
Report Facts
Census: 67
Total Capacity: 67
Medication administration counts: 24
Medication administration counts: 17
Medication administration counts: 11
Medication administration counts: 46
Medication administration counts: 30
Medication administration counts: 20
Medication administration counts: 12
Medication administration counts: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Lewis | Administrator | Signed report and involved in administrative oversight |
| LPN 3 | Involved in medication errors and narcotic documentation discrepancies for Residents G, F, and K | |
| LPN 4 | Witnessed concerns regarding narcotic destruction and documentation | |
| Director of Nursing | DON | Provided Controlled Drug Records, interviewed regarding narcotic discrepancies and policies |
Inspection Report
Re-Inspection
Census: 57
Capacity: 80
Deficiencies: 0
May 30, 2023
Visit Reason
This was a Post Survey Revisit (PSR) to the Emergency Preparedness survey and Life Safety Code Recertification and State Licensure Survey conducted on 04/05/23.
Findings
At this PSR survey, Woodland Manor was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements for Medicare and Medicaid Participating Providers and Suppliers.
Report Facts
Certified beds: 80
Census: 57
Inspection Report
Routine
Census: 69
Capacity: 80
Deficiencies: 18
Apr 5, 2023
Visit Reason
Routine Emergency Preparedness and Life Safety Code Recertification survey conducted by the Indiana Department of Health.
Findings
The facility was found in substantial compliance with Emergency Preparedness requirements but had multiple deficiencies related to Life Safety Code including emergency power system testing, means of egress obstructions, fire door inspections, fire alarm system maintenance, sprinkler system accessibility and maintenance, fire extinguisher storage, water heater inspections, electrical junction safety, fire drills, smoking area maintenance, oxygen cylinder storage, and staff training on oxygen transfilling.
Severity Breakdown
SS=F: 8
SS=E: 8
SS=C: 1
Deficiencies (18)
| Description | Severity |
|---|---|
| Failed to maintain required testing documentation for emergency power generator including monthly load testing and 4-hour load test every three years. | SS=C |
| Kitchen cooler door locked from outside with no release mechanism inside, risking staff entrapment. | SS=E |
| Corridor means of egress obstructed by storage and vending machine. | SS=E |
| Exit door by room 300 was magnetically locked without posted exit code, delaying egress. | SS=E |
| Corridor width reduced by unsecure furniture not affixed to floor or wall. | SS=E |
| Dead-end corridor exceeded 30 feet without proper exit signage or posted code. | SS=E |
| Exit discharge path through parking lot was uneven with potholes, lacking safe level walking surface. | SS=E |
| Incomplete documentation and testing of 47 battery operated smoke alarms in resident rooms. | SS=F |
| Laundry room containing fuel fired equipment had unsealed penetrations in ceiling compromising smoke resistance. | SS=E |
| Staff lacked access to shutoff switches for cooktops in therapy gym and activities room. | SS=E |
| Four portable fire extinguishers in maintenance and mechanical rooms were unsecured and sitting on floor. | SS=E |
| Two fuel fired water heaters lacked current inspection certificates; last documented inspection expired December 2021. | SS=F |
| Electrical junction box in records storage room was uncovered with exposed wiring. | SS=E |
| Fire drills were not conducted on all shifts for three quarters of 2022. | SS=F |
| Smoking areas were not maintained; cigarette butts found on ground and planters. | SS=E |
| Annual inspection and testing of four fire door assemblies not completed; rolling fire door last tested in 2018; fire door labels obscured by paint; smoke door by room 123 damaged with holes. | SS=F |
| Oxygen cylinder in resident room 113 was not properly secured; full and empty oxygen cylinders in storage room were mixed and not marked. | SS=E |
| Staff training on oxygen transfilling procedures was not documented. | SS=F |
Report Facts
Certified beds: 80
Census: 69
Fire door assemblies: 4
Battery operated smoke alarms: 47
Fire extinguishers unsecured: 4
Fuel fired water heaters: 2
Oxygen cylinders: 10
Fire drills missing: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Lewis | Administrator | Named in relation to review of findings and exit conference |
Inspection Report
Annual Inspection
Census: 66
Capacity: 66
Deficiencies: 15
Mar 21, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of multiple complaints.
Findings
The facility had multiple deficiencies including issues with resident funds management, baseline and comprehensive care plans, ADL care, activities programming, quality of care including medication administration and catheter care, nutrition, pharmacy services, medication storage, food safety, and environmental conditions.
Complaint Details
This visit included the Investigation of Complaints IN00388683, IN00394202, IN00394334, IN00394560 and IN00404072. Deficiencies related to these complaints were cited at various tags including F921, F686, F689.
Severity Breakdown
SS=D: 13
SS=E: 2
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to ensure residents could withdraw personal funds on weekends and evenings. | SS=D |
| Failed to develop baseline care plan for Foley catheter use within 48 hours of admission. | SS=D |
| Failed to develop comprehensive care plan for skin issues. | SS=D |
| Failed to provide showers for 7 of 7 residents reviewed for ADL care. | SS=E |
| Failed to follow physician orders to hold insulin and use positioning devices and TED hose. | SS=D |
| Failed to provide timely skin treatment for a resident with stage 2 pressure ulcer. | SS=D |
| Failed to identify fall risk for a resident. | SS=D |
| Failed to maintain urinary catheter care and drainage bag position. | SS=D |
| Failed to follow dietary recommendation for diet change. | SS=D |
| Failed to ensure ordered medications were administered per physician orders. | SS=D |
| Failed to ensure pharmacy medication reviews were documented with physician response. | SS=D |
| Failed to ensure medication carts were locked when unattended, medications properly labeled and dated, and stored under proper conditions. | SS=D |
| Failed to store and prepare food in a sanitary manner in kitchen and resident pantries. | SS=D |
| Failed to maintain a safe, clean, and comfortable environment including issues with temperature, plumbing, electrical, and cleanliness in resident areas. | SS=E |
| Failed to provide treatment and care to prevent urinary tract infections and provide appropriate catheter care. | SS=D |
Report Facts
Survey dates: 7
Census: 66
Total capacity: 66
Medication error rate: 6.9
Residents reviewed for medication errors: 9
Residents reviewed for ADL care: 7
Residents reviewed for pharmacy medication irregularities: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Lewis | Administrator | Signed the report |
| LPN 2 | Mentioned in medication administration errors and medication storage observations | |
| Director of Nursing | Director of Nursing | Mentioned in multiple interviews regarding care plans, medication administration, catheter care, and pharmacy recommendations |
| Activity Director | Activity Director | Mentioned in relation to activities program deficiencies |
| QMA 13 | Mentioned in relation to shower provision and food storage | |
| LPN 3 | Mentioned in medication storage observations | |
| LPN 11 | Mentioned in pantry observation | |
| LPN 12 | Mentioned in refrigerator temperature log interview | |
| Cook 15 | Mentioned in food preparation observation | |
| Maintenance Director | Maintenance Director | Mentioned in environmental observations and interviews |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 21, 2023
Visit Reason
Paper Compliance to the Recertification and State Licensure Survey and Investigation of Complaints IN00388683, IN00394202, IN00394334, IN00394560 and IN00404072.
Findings
Woodland Manor was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 regarding the Paper Compliance Review to the Recertification and State Licensure Survey and Complaint Investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 15, 2022
Visit Reason
Paper compliance review to the investigation of complaints IN00377252, IN00382963, and IN00381936.
Findings
Woodland Manor was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 regarding the paper compliance review of the specified complaints.
Complaint Details
Investigation of complaints IN00377252, IN00382963, and IN00381936; facility found in compliance.
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