Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
WOODLAND MANOR
ELKHART, IN · 80 certified beds · Last Life Safety survey November 21, 2025
CMS Certification Number 155086 · first certified February 1969
Ownership
Operated by ADAMS COUNTY MEMORIAL HOSPITAL · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within IN
28 citations — more than 84% of the 507 certified nursing homes in IN. Compared within IN rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 4 citations; the earlier surveys in the window averaged 12. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens October 2026 — about 1 month from now. This facility’s last Life Safety survey was November 2025. Facilities in IN are typically surveyed 11–14 months after the last one (median 13), measured over 883 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
11 of the 28 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
10 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 28 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
How that compares
Compared with the median facility in IN, and nationally. Surveyors differ markedly between states, so the IN figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 28 |
| Median facility in IN | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 14, 2024 | 17 |
| May 5, 2025 | 7 |
| November 21, 2025 | 4 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2025-11-21 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2025-05-05 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2025-11-21 |
| K-0300 | Meet other general requirements that are deficient. | 1 | 2025-05-05 |
| E-0007 | Address patient/client population and determine types of services needed. | 1 | 2024-11-14 |
| E-0035 | Provide family notifications of emergency plan. | 1 | 2024-11-14 |
| E-0039 | Conduct testing and exercise requirements. | 1 | 2024-11-14 |
| E-0013 | Develop Emergency Preparedness policies and procedures. | 1 | 2024-11-14 |
What the citations cover
- Emergency Preparedness Deficiencies 11
- Smoke Deficiencies 8
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Miscellaneous Deficiencies 3
- Other 2
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 11 |
| Smoke Deficiencies | 8 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Miscellaneous Deficiencies | 3 |
| Services Deficiencies | 1 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
November 21, 2025 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (December 17, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (December 17, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 17, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 17, 2025) |
May 5, 2025 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0300 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (June 20, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (June 20, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 20, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (June 20, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (June 20, 2025) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (June 20, 2025) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (June 20, 2025) |
November 14, 2024 — 17 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (January 22, 2025) |
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (January 22, 2025) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (January 22, 2025) |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (January 22, 2025) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (January 22, 2025) |
| E-0032 | Provide primary/alternate means for communication. | Deficient, Provider has date of correction (January 22, 2025) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (January 22, 2025) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (January 22, 2025) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (January 22, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (January 26, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (January 22, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (January 22, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (January 22, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (January 22, 2025) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (January 22, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (January 22, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (January 22, 2025) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.