Inspection Reports for
Atria Woodbriar Park

Emergency call response: In the months of June 2024 and December 2023 there were 70 e-call response times over the ten minutes required by the Residence policy (repeat finding).

Memory care unit: Documentation to support the required Bi-annual Special Care Residence operations review was missing for the second half of calendar year 2022 and all of calendar year 2023.

Resident screening and assessment: Four resident records were missing documentation of the Legal Representative and the scope of authority.

Quality assurance program: Documentation of a set target date for follow-up action and person responsible for follow up action was missing for calendar year 2023, and documentation of Resident Safety Assurances and Evidence Informed Falls Prevention Program audits were missing for multiple years. Additionally, medication assistance documentation was incomplete (repeat finding).

Incident reporting: The Residence filed 52 incident reports greater than 24 hours after the occurrence of the incident during the period reviewed (repeat finding). Documentation of missing person drills for second and third shifts was also missing for 2023.

Staff training: Documentation to support that the Residence conducted a training needs assessment in the 2022 calendar year was missing.

Resident records: The Residence did not use the Correspondence Log to communicate all significant or pertinent information necessary to maintain the continuity of care for all Residents and did not consistently document for each 24-hour period in each Correspondence Log.