Inspection Reports for
Woodbriar Nursing Home
204 Catherine St, Harrisburg, AR 72432, AR, 72432
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
54% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Oct 10, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care planning, nursing assistant training and certification, and arbitration agreement provisions at Woodbriar Nursing Home.
Findings
The facility failed to develop and implement a complete person-centered care plan for a resident requiring anticoagulant medication, failed to ensure five nursing assistants completed competency training and certification within required timeframes, and failed to include provisions for a neutral arbitrator and convenient venue in the arbitration agreement.
Deficiencies (3)
Failed to document and complete a person-centered care plan for Resident #38 involving anticoagulants or Eliquis.
Failed to ensure five Nursing Assistants completed competency training and certification testing within 120 days from completion of initial training.
Failed to include selection of a neutral arbitrator agreed upon by both parties and selection of a venue convenient to both parties in the Arbitration Agreement.
Report Facts
Number of Nursing Assistants: 5
Initial training completion dates: NA #1: 2023-11-21, NA #2: 2023-12-21, NA #3: 2024-04-08, NA #4: 2024-05-02, NA #5: 2024-02-06
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed regarding care plan for Resident #38 | |
| Human Resources/Social Services (HR/Social) | Interviewed regarding nursing assistant training and certification | |
| Administrator | Interviewed regarding nursing assistant training policy and arbitration agreement |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Oct 10, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to care planning, nursing assistant training and certification, and arbitration agreement provisions.
Findings
The facility failed to develop and implement a complete person-centered care plan for a resident involving anticoagulant medication, failed to ensure nursing assistants completed competency training and certification within required timeframes, and failed to include provisions for a neutral arbitrator and convenient venue in the arbitration agreement.
Deficiencies (3)
Failed to document and complete a person-centered care plan for anticoagulant medication for Resident #38.
Failed to ensure five Nursing Assistants completed competency training and certification testing within 120 days from initial training.
Failed to include selection of a neutral arbitrator agreed upon by both parties and a venue convenient to both parties in the Arbitration Agreement.
Report Facts
Number of Nursing Assistants not certified: 5
Initial training completion dates: NA #1 completed 11/21/2023, NA #2 completed 12/21/2023, NA #3 completed 04/08/2024, NA #4 completed 05/02/2024, NA #5 completed 02/06/2024.
Assessment Reference Date: Resident #38's MDS assessment reference date was 2024-08-13.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed regarding lack of care planning for anticoagulants. | |
| Human Resources/Social Services (HR/Social) | Interviewed regarding Nursing Assistants' training and certification status and arbitration agreement. | |
| Administrator | Interviewed regarding Nursing Assistants' certification timeline and arbitration agreement. |
Inspection Report
Deficiencies: 5
Date: Aug 18, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, confidentiality, personal care, respiratory care, infection control, and other aspects of nursing home care at Woodbriar Nursing Home.
Findings
The facility was found deficient in multiple areas including failure to respect resident dignity and privacy by locking a resident's bathroom door, failure to secure confidential medical information on an open laptop, inadequate personal hygiene care for a resident's fingernails, failure to ensure residents received oxygen therapy at the physician ordered flow rate, and failure to prevent potential infection and cross contamination in the laundry area due to food and drinks being placed next to clean linens.
Deficiencies (5)
Failed to treat residents with respect, dignity, and protect their right to a dignified existence and privacy by locking Resident #16's bathroom door and denying use of bedside commode.
Failed to keep residents' personal and medical records private and confidential by leaving an open laptop with resident information visible in the hallway.
Failed to ensure fingernails were clean, groomed, and free from chipped nail polish for Resident #51 dependent on staff for nail care.
Failed to ensure residents received oxygen therapy at the physician ordered flow rate for Residents #17 and #19.
Failed to prevent potential infection and cross contamination in the laundry processing area by allowing food and drinks on the laundry folding table next to clean, folded resident linens.
Report Facts
Residents affected: 1
Residents affected: 13
Residents affected: 16
Residents affected: 2
Residents affected: 18
Residents affected: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nursing Assistant | Named in bathroom door locking and toileting process finding |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding Resident #16 toileting process and care plan |
| ADON | Assistant Director of Nursing | Interviewed regarding bathroom door locking policy and oxygen therapy responsibility |
| RN #1 | Registered Nurse | Interviewed regarding privacy breach with open laptop and oxygen therapy |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding nail care for Resident #51 |
| CNA #3 | Certified Nurse's Aide | Interviewed regarding assistance with Resident #51's activities of daily living and nail care |
| CNA #4 | Certified Nurse's Aide | Interviewed regarding assistance with Resident #51's activities of daily living and nail care |
| Housekeeping/Laundry Supervisor | Interviewed regarding food and drinks on laundry folding counter | |
| Administrator | Interviewed regarding infection control and laundry practices |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 18, 2023
Visit Reason
The inspection was conducted based on complaints regarding resident rights violations, confidentiality breaches, inadequate personal hygiene care, improper oxygen therapy administration, and infection control issues in the facility.
Complaint Details
The visit was complaint-related, triggered by allegations of resident rights violations, confidentiality breaches, inadequate personal hygiene care, improper oxygen therapy administration, and infection control lapses. Substantiation status is not explicitly stated.
Findings
The facility failed to respect residents' rights by locking a resident's bathroom door and restricting use of a bedside commode, failed to secure confidential resident information on an open laptop, did not maintain proper personal hygiene for a resident dependent on staff for nail care, failed to ensure oxygen therapy was administered at physician-ordered flow rates for residents, and allowed potential infection control risks by permitting food and drinks on the laundry folding counter next to clean linens.
Deficiencies (5)
Failed to treat residents with respect and dignity by locking bathroom door and restricting bedside commode use for Resident #16.
Failed to keep residents' personal and medical records private and confidential by leaving an open laptop with resident information visible in the hallway.
Failed to ensure fingernails were clean, groomed, and free from chipped nail polish for Resident #51 dependent on staff for nail care.
Failed to provide oxygen therapy at the physician ordered flow rate for Residents #17 and #19.
Failed to prevent potential infection and cross contamination by allowing food and drinks on the laundry folding counter next to clean resident linens.
Report Facts
Residents affected: 1
Residents affected: 13
Residents affected: 16
Residents affected: 2
Residents affected: 18
Residents census on 200 Hall: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nursing Assistant | Named in findings related to locking bathroom door and toileting procedures for Resident #16 |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding Resident #16 toileting procedures and oxygen therapy for Resident #17 |
| RN #1 | Registered Nurse | Interviewed regarding confidentiality breach and oxygen therapy for Resident #19 |
| ADON | Assistant Director of Nursing | Interviewed regarding toileting procedures, confidentiality breach, nail care, and oxygen therapy responsibilities |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding nail care for Resident #51 |
| CNA #3 | Certified Nurse's Aide | Interviewed regarding assistance with activities of daily living and nail care for Resident #51 |
| CNA #4 | Certified Nurse's Aide | Interviewed regarding assistance with activities of daily living and nail care for Resident #51 |
| Housekeeping/Laundry Supervisor | Interviewed regarding infection control issue with food and drinks on laundry folding counter | |
| Administrator | Interviewed regarding infection control issue and general facility policies |
Inspection Report
Routine
Census: 66
Deficiencies: 4
Date: May 6, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident trust fund management, Minimum Data Set (MDS) discharge assessments, food safety and sanitation, and infection prevention and control practices.
Findings
The facility failed to properly reconcile resident trust funds, incorrectly coded a resident's discharge MDS, did not ensure proper dating and cleanliness of food items and equipment, and failed to enforce appropriate PPE use for a resident on contact isolation, posing potential minimal to actual harm to residents.
Deficiencies (4)
Failed to ensure proper bookkeeping techniques to accurately reconcile individual resident trust funds for 22 of 22 sampled residents.
Failed to ensure a Minimum Data Set (MDS) Discharge assessment was encoded correctly for 1 of 2 sampled discharged residents.
Failed to ensure food items in the refrigerator were dated when pulled from the freezer and placed in the refrigerator, failed to maintain equipment cleanliness, and failed to ensure regular cleaning of one ice machine.
Failed to ensure appropriate PPE was worn for a resident on contact isolation and staff removed masks when talking within three feet of the resident.
Report Facts
Residents affected: 56
Residents affected: 63
Residents affected: 18
Total census: 66
Residents affected: 1
Residents sampled: 22
Residents sampled: 2
Residents sampled: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in infection control finding for not wearing appropriate PPE entering Resident #33's room |
| CNA #2 | Certified Nursing Assistant | Named in infection control finding for PPE knowledge and training of CNAs |
| CNA #3 | Certified Nursing Assistant | Mentioned in infection control finding advising PPE use |
| CNA #5 | Certified Nursing Assistant | Named in infection control finding for removing mask within three feet of Resident #33 |
| Director of Nursing | Director of Nursing | Interviewed regarding MDS discharge assessment and PPE practices |
| Maintenance Director | Maintenance Director | Interviewed regarding ice machine cleaning and maintenance logs |
| MDS Coordinator | MDS Coordinator | Responsible for correcting discharge MDS coding for Resident #59 |
| Administrator | Administrator | Provided statements regarding MDS discharge correction and mask wearing policy |
| Business Office Manager | Business Office Manager | Provided trust fund reports and petty cash balance information |
| Dietary Employee #1 | Dietary Employee | Provided information on ice machine use and cleaning |
| Dietary Employee #2 | Dietary Employee | Interviewed about food thawing and refrigerator cleanliness |
Inspection Report
Routine
Census: 66
Deficiencies: 4
Date: May 6, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including proper management of resident trust funds, accuracy of Minimum Data Set (MDS) discharge assessments, food safety and sanitation practices, and infection prevention and control measures.
Findings
The facility was found deficient in properly managing resident trust funds, accurately coding MDS discharge assessments, maintaining food safety standards including proper dating and cleaning of food storage and ice machines, and ensuring staff compliance with infection control protocols including appropriate use of PPE for residents on isolation.
Deficiencies (4)
Failed to ensure proper bookkeeping techniques to accurately reconcile individual resident trust funds for 22 of 22 sampled residents.
Failed to ensure a Minimum Data Set (MDS) Discharge assessment was encoded correctly for 1 of 2 sampled discharged residents.
Failed to ensure food items in the refrigerator were dated when pulled from the freezer and placed in the refrigerator and failed to ensure equipment was maintained in clean condition including ice machines.
Failed to ensure appropriate PPE was worn for a resident on contact isolation and staff did not remove face masks when talking within three feet of the resident.
Report Facts
Residents affected: 22
Residents affected: 56
Trust Fund Report balance: 44467.66
Trust Fund Current Account Balance: 40123.71
Petty cash balance: 225.04
Total census: 66
Residents affected: 63
Residents affected: 18
Residents affected: 1
Residents sampled: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding MDS discharge assessment and PPE compliance |
| MDS Coordinator | MDS Coordinator | Responsible for completing and correcting discharge MDS |
| Business Office Manager | Business Office Manager | Provided trust fund reports and petty cash information |
| Dietary Employee #1 | Dietary Employee | Provided list of residents receiving meals and ice, described ice machine condition |
| Dietary Employee #2 | Dietary Employee | Interviewed about food thawing and refrigerator conditions |
| Maintenance Director | Maintenance Director | Provided information on ice machine cleaning and maintenance logs |
| CNA #1 | Certified Nursing Assistant | Observed not wearing appropriate PPE entering isolation room |
| CNA #2 | Certified Nursing Assistant | Provided information on isolation type and PPE training |
| CNA #5 | Certified Nursing Assistant | Observed pulling mask down within three feet of resident and interviewed about mask use |
| Administrator | Administrator | Provided statements on mask wearing policy and ice machine cleaning documentation |
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