Inspection Reports for
Woodland Hills Healthcare and Rehabilitation
1320 West Braden Street, Jacksonville, AR, 72076
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
11.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
125% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
43% occupied
Based on a December 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 52
Deficiencies: 10
Date: Dec 18, 2024
Visit Reason
Routine inspection to assess compliance with healthcare facility regulations including resident care, medication management, infection control, environment safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate snacks for diabetic residents, improper medication self-administration practices, incomplete PASRR screening, inadequate discharge summaries, unsecured hazardous areas and medication storage, unsanitary kitchen and food handling conditions, insufficient staffing and infection preventionist hours, poor infection control practices, and non-functioning call light systems in resident rooms.
Deficiencies (10)
Failed to provide appropriate snacks for diabetic residents, specifically Resident #34 was given high sugar snacks instead of protein or complex carbohydrates.
Resident #351 self-administered inhaler and updraft without approval or staff presence, risking improper medication use.
Failed to complete Level 1 PASRR screening for Resident #15 with mental disorders.
Failed to provide a complete discharge summary including medication reconciliation for Resident #49.
Shower rooms, personal care storeroom, and treatment/oxygen room were unlocked, exposing residents to hazardous items like razors, scissors, chemicals, and sharps.
Medication cart was unlocked with exposed sharps and numerous medications accessible, risking resident harm.
Failed to maintain kitchen and food preparation areas in sanitary condition, including dirty ice machine, greasy vents, chipped floors, expired food, and improper food temperatures.
Facility assessment failed to address adequate Infection Preventionist staffing hours based on resident needs and census.
Failed to provide adequate infection prevention and control, including unclean shower beds, dirty beauty shop equipment, soiled lifts, and unsanitary resident rooms and snack areas.
Call light system was non-functional for Residents #7 and #30, preventing residents from summoning staff in emergencies.
Report Facts
Residents census: 52
Infection Preventionist average weekly hours: 8.25
Medication counts: 73
Medication counts: 22
Food temperature: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Observed unlocked medication cart and identified medications inside |
| ADON | Assistant Director of Nursing | Expressed concerns about unlocked medication cart and sharps container |
| DON | Director of Nursing | Interviewed regarding medication storage, infection preventionist staffing, and call light system |
| Administrator | Interviewed regarding staffing, infection preventionist availability, and facility cleanliness | |
| CNA #4 | Certified Nursing Assistant | Reported use and cleaning practices of clippers in beauty shop |
| CNA #9 | Certified Nursing Assistant | Reported non-functioning call light for Resident #30 |
| Maintenance Director | Reported informal process for repair requests and occasional forgotten maintenance tasks | |
| Dietary Supervisor | Provided kitchen cleaning policy and observations |
Inspection Report
Routine
Deficiencies: 2
Date: May 23, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with care standards, focusing on bathing and personal hygiene for dependent residents, and the maintenance of safe and palatable food temperatures for residents receiving meals in their rooms.
Findings
The facility failed to provide consistent bathing and personal hygiene for four dependent residents, resulting in hygiene and potential skin issues. Additionally, the facility failed to maintain safe and appetizing food temperatures for meals served to residents in their rooms, with documented food temperatures below recommended levels.
Deficiencies (2)
Failure to provide consistent bathing and personal hygiene for 4 dependent residents to maintain hygiene and prevent infection and skin issues.
Failure to maintain safe and palatable food temperatures for trays served to residents who receive meals in their room.
Report Facts
Residents affected: 4
BIMS score: 8
BIMS score: 15
BIMS score: 1
BIMS score: 5
Shower frequency: 3
Showers documented: 5
Showers documented: 4
Bathes documented: 2
Food temperature: 175
Food temperature: 40
Food temperature: 160
Food temperature: 40
Food temperature: 170
Food temperature: 170
Food temperature: 170
Food temperature: 40
Food temperature: 102
Food temperature: 90
Food temperature: 90
Food temperature: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Interviewed about time available to complete baths | |
| Director of Nursing (DON) | Provided facility policy on bedbaths and commented on food temperature concerns | |
| Dietary Manager | Accompanied surveyor to check food temperatures and commented on food temperature issues |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Nov 22, 2023
Visit Reason
The survey was conducted as a recertification annual inspection to assess compliance with regulatory requirements for Woodland Hills Healthcare and Rehabilitation.
Findings
The facility was found deficient in multiple areas including call light accessibility, maintaining a safe and homelike environment, nail care, treatment and care according to physician orders, respiratory care and oxygen equipment maintenance, medication administration practices, medication storage, food storage and safety, arbitration agreement procedures, and infection prevention and control. Deficiencies were generally cited at a minimal harm level affecting some or few residents.
Deficiencies (12)
Failed to ensure call lights were placed within resident's reach to allow resident to request assistance.
Failed to provide a safe, clean, comfortable, and homelike environment including bathroom cleanliness and wall repairs.
Failed to ensure fingernails were clean and trimmed to promote good grooming and hygiene.
Failed to ensure a resident required to wear a compression sleeve and glove received care and treatment in accordance with physician's plan of care.
Failed to provide safe and appropriate respiratory care including cleanliness and maintenance of oxygen equipment and tubing.
Failed to ensure licensed nurses demonstrated competency with necessary care, treatment, safety, and services required by each resident, including medication administration and medication cart security.
Failed to ensure refrigerated narcotic medications were stored in a permanently affixed container and insulin bottles were dated and discarded after expiration.
Failed to ensure food was used prior to use by date and stored properly to minimize potential for food borne illness.
Failed to ensure binding arbitration agreement was written in a language/manner understandable to residents/representatives and that proper signatures and rescindment periods were documented.
Failed to provide a neutral and fair arbitration process including selection of arbitrator and venue.
Failed to develop and implement appropriate Quality Assurance and Performance Improvement (QAPI) plans to prevent repeated deficiencies in multiple areas including environment, nail care, sanitation, and infection control.
Failed to implement appropriate infection prevention and control procedures during medication administration to prevent possible transmission of communicable diseases and infections.
Report Facts
Residents affected: 1
Residents affected: 47
Residents affected: 16
Residents affected: 16
Residents affected: 8
Residents affected: 65
Residents affected: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration and infection control deficiencies |
| LPN #2 | Licensed Practical Nurse | Named in respiratory care and medication storage deficiencies |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including call light accessibility, respiratory care, medication administration, and QAPI |
| Admissions Director | Admissions Director | Interviewed regarding arbitration agreement deficiencies |
| Administrator | Facility Administrator | Interviewed regarding arbitration agreement and QAPI |
| Dietary Manager | Dietary Manager | Named in food storage deficiency and QAPI |
Inspection Report
Routine
Census: 16
Deficiencies: 1
Date: Jun 1, 2023
Visit Reason
The inspection was conducted to ensure the nursing home area was free from accident hazards and provided adequate supervision to prevent accidents, specifically focusing on the storage and containment of medications, razors, and shaving supplies.
Findings
The facility failed to ensure that medications, razors, and shaving supplies were properly stored and contained to prevent potential accidental ingestion or injury to cognitively impaired residents who could ambulate. Multiple staff confirmed that these items should be locked up and shower rooms should not be left open or unlocked when not in use.
Deficiencies (1)
Medications, razors, and shaving supplies were not stored and contained to prevent potential accidental ingestion or injury to cognitively impaired residents on multiple halls.
Report Facts
Residents affected: 16
Inspection Report
Routine
Deficiencies: 10
Date: Dec 1, 2022
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with federal and state regulations related to resident care, facility maintenance, abuse reporting, infection control, and dietary services.
Findings
The facility was found deficient in multiple areas including failure to invite residents to care plan conferences, inadequate maintenance of resident rooms with damaged walls, delayed reporting of an abuse allegation, failure to provide proper grooming care for a resident, lack of monitoring for side effects of psychoactive medications, failure to provide milk as per the menu, improper food storage and dish sanitation in the kitchen, lack of a licensed administrator, ineffective maintenance system, and failure to post isolation precaution signage for residents with influenza.
Deficiencies (10)
Failed to invite residents #4, #21, and #40 to participate in care plan conferences.
Walls in multiple resident rooms were damaged with holes and gouges, and repairs were not completed timely.
Failure to report an allegation of abuse involving Resident #23 to the state survey agency within the required timeframe.
Resident #44 was not regularly offered trimming or shaving of facial hair and trimming of nails to maintain good grooming and hygiene.
Failure to monitor Resident #4 for side effects of antidepressant medication as required by care plan.
Facility failed to provide milk with breakfast and/or dinner as per the menu for five days affecting all residents on a regular diet.
Food stored in walk-in refrigerator was not labeled, dated, or stored off the floor; dishes and pans were stored wet; chipped plates were used to serve residents.
Facility administration failed to ensure the acting administrator was knowledgeable regarding abuse reporting requirements and failed to maintain a reliable maintenance system during a period with no maintenance staff.
Facility's governing body failed to employ a licensed administrator for the period of September 2022 through 12/01/2022.
Facility failed to post isolation precaution signage on doors of residents with influenza to indicate required PPE for staff and visitors.
Report Facts
Residents affected by care plan participation deficiency: 3
Residents affected by wall damage deficiency: 12
Residents affected by abuse reporting deficiency: 1
Residents affected by grooming care deficiency: 1
Residents affected by medication monitoring deficiency: 1
Residents affected by milk provision deficiency: 47
Residents affected by food storage and dish sanitation deficiency: 47
Residents affected by lack of licensed administrator: 47
Residents affected by isolation signage deficiency: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Named in abuse allegation reporting deficiency related to Resident #23. |
| Social Services Director/Manager with Administrative Duties | Acting Administrator | Named in failure to report abuse timely and lack of licensed administrator. |
| CNA #8 | Certified Nursing Assistant | Mentioned in relation to wall damage and grooming care deficiencies. |
| CNA #9 | Certified Nursing Assistant | Mentioned in relation to grooming care deficiency. |
| Director of Nursing | Director of Nursing | Mentioned in multiple interviews related to deficiencies in care and maintenance. |
| Consultant Pharmacist | Pharmacist | Interviewed regarding monitoring of psychoactive medication side effects. |
| Consultant CST #16 | Consultant | Mentioned regarding administrator licensing and training. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding isolation signage and medication monitoring. |
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