Cycle 1
Health 2025-11-21 · Fire 2025-11-21
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Elkhart, IN
Woodland Manor
1-star overall rating with 1-star inspections with $114,339 in total fines with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
343 S Nappanee St, Elkhart, IN
(574) 295-0096
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
70
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Adams County Memorial Hospital
Operator or chain grouping
Approved since
1969-02-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.45
Registered nurse staffing
LPN hours / resident day
1.03
Licensed practical nurse staffing
Aide hours / resident day
2.30
Nurse aide staffing
Weekend hours
3.31
Weekend nurse staffing
RN turnover
82%
Annual RN turnover
Total nurse turnover
71%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.1% |
93.6%
2.5 pts better
|
93.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.4%
4.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
3.8%
0.5 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 22.7% |
24.6%
1.9 pts better
|
11.4%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.2% |
5.6%
1.4 pts better
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.6% |
23.5%
8.9 pts better
|
19.6%
5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 26.5% |
14.8%
11.7 pts worse
|
16.7%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 25.7% |
13.3%
12.4 pts worse
|
16.3%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.5% |
11.7%
12.8 pts worse
|
14.9%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.4%
0.8 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.7% |
1.2%
1.5 pts worse
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.9% |
24.2%
6.7 pts worse
|
19.8%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
4.1%
2.2 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.4% |
81.6%
0.8 pts better
|
81.7%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.2% |
10.5%
10.7 pts worse
|
12.0%
9.2 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 70.3% |
79.0%
8.7 pts worse
|
79.7%
9.4 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.2% |
22.4%
5.8 pts worse
|
23.9%
4.3 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2025-05-05 · Fire 2025-05-05
19 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2024-11-14 · Fire 2024-11-14
24 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
17 fire-safety deficiencies
Top issue: Emergency Preparedness (10 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-11-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-12-17
E · Potential for more than minimal harm
2025-11-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-12-17
C · Minimal harm
2025-11-21
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-12-17
C · Minimal harm
2025-11-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-12-17
F · Potential for more than minimal harm
2025-05-05
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-05-05
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-05-05
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-05-05
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-05-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-05-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-20
C · Minimal harm
2025-05-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-20
F · Potential for more than minimal harm
2024-11-14
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-01-22
F · Potential for more than minimal harm
2024-11-14
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2025-01-22
F · Potential for more than minimal harm
2024-11-14
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2025-01-22
F · Potential for more than minimal harm
2024-11-14
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2025-01-22
F · Potential for more than minimal harm
2024-11-14
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-01-22
F · Potential for more than minimal harm
2024-11-14
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-01-22
F · Potential for more than minimal harm
2024-11-14
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-01-22
F · Potential for more than minimal harm
2024-11-14
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-01-26
F · Potential for more than minimal harm
2024-11-14
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-01-22
F · Potential for more than minimal harm
2024-11-14
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-01-22
F · Potential for more than minimal harm
2024-11-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-11-14
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-11-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-11-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-11-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-11-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-11-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-22
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-21
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-11-21
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-11-21
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-11-21
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-11-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-11-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-11-21
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-11-21
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-11-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-09-15
F742 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-09-26
D · Potential for more than minimal harm
2025-05-05
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-05-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-05-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-05-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-05-05
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-05-05
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-05-23
C · Minimal harm
2025-05-05
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2025-05-23
G · Actual harm
2025-02-28
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-03-21
G · Actual harm
2025-02-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-28
G · Actual harm
2025-02-28
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-28
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-28
F · Potential for more than minimal harm
2024-11-14
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-12-14
F · Potential for more than minimal harm
2024-11-14
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-12-14
E · Potential for more than minimal harm
2024-11-14
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-01-24
E · Potential for more than minimal harm
2024-11-14
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-12-14
E · Potential for more than minimal harm
2024-11-14
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2024-12-14
E · Potential for more than minimal harm
2024-11-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-24
E · Potential for more than minimal harm
2024-11-14
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-12-14
E · Potential for more than minimal harm
2024-11-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-14
F622 · Resident Rights Deficiencies
Health
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.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-26
D · Potential for more than minimal harm
2024-11-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-01-24
D · Potential for more than minimal harm
2024-11-14
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-24
D · Potential for more than minimal harm
2024-11-14
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-14
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-01-24
D · Potential for more than minimal harm
2024-11-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-24
D · Potential for more than minimal harm
2024-11-14
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-01-24
D · Potential for more than minimal harm
2024-11-14
F887 · Infection Control Deficiencies
Health
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.
Corrected 2025-01-24
D · Potential for more than minimal harm
2024-09-06
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-09-27
G · Actual harm
2024-06-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-05
E · Potential for more than minimal harm
2024-05-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-05
E · Potential for more than minimal harm
2024-05-17
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-07-05
G · Actual harm
2024-03-06
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-03-08
D · Potential for more than minimal harm
2023-12-21
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-12-21
F622 · Resident Rights Deficiencies
Health
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.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-08-09
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-09
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-09-15
E · Potential for more than minimal harm
2023-03-21
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-05-08
D · Potential for more than minimal harm
2023-03-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-08
D · Potential for more than minimal harm
2023-03-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-08
Penalties and ownership
What sits behind the stars
$79,284
2025-02-28
Fine
Fine · fine $79,284
Fine
$35,055
2024-05-17
Fine
Fine · fine $35,055
Fine
$0
2024-05-17
Payment Denial
Payment Denial · denial start 2024-06-20 · 29 days
29 day denial
Ownership
Adams County Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Adams County Memorial Hospital
Operational/Managerial Control · Organization
Borne-Bauman, Candice
Operational/Managerial Control · Individual
Cibc Bank Usa
5% Or Greater Mortgage Interest · Organization
Fernandes, Taryn
Operational/Managerial Control · Individual
Flueckiger, Russell
Operational/Managerial Control · Individual
Lehman, Scott
Operational/Managerial Control · Individual
Macklin, Larry
Operational/Managerial Control · Individual
Mcintire, David
Operational/Managerial Control · Individual
Moore, Leslie
Operational/Managerial Control · Individual
Smith, Scott
Operational/Managerial Control · Individual
Sprunger, Kyle
Operational/Managerial Control · Individual
Wheeler, Dane
Operational/Managerial Control · Individual
Woodland Nursing And Rehab LLC
Operational/Managerial Control · Organization
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#3
Greenleaf Health Campus
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3-star overall rating with 2-star inspections with 7 recent health deficiencies
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