Inspection Reports for
Woodruff County Health Center
139 West Highway 64, McCrory, AR 72101, AR, 72101
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
117% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 18, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to ensure safe transfer procedures and infection control practices in the facility.
Complaint Details
The complaint investigation substantiated that CNA #3 transferred Resident #107 alone using a mechanical lift contrary to the care plan, causing skin tears and resulting in CNA #3's termination. Infection control deficiencies were observed with staff failing to wear appropriate PPE during care of residents on Enhanced Barrier Precautions, including medication administration and tracheostomy care.
Findings
The facility failed to ensure safe mechanical lift transfers for Resident #107, resulting in injury due to staff not following the care plan requiring two-person assistance. Additionally, the facility failed to implement infection prevention and control practices in accordance with Enhanced Barrier Precautions (EBP) for Residents #1 and #2, including improper use of personal protective equipment (PPE) during medication administration and tracheostomy care.
Deficiencies (2)
Failure to ensure safe transfer procedures using a mechanical lift, resulting in injury to Resident #107.
Failure to implement infection prevention and control program, including improper use of PPE during care of residents on Enhanced Barrier Precautions.
Report Facts
Residents reviewed for accidents and supervision: 8
Residents reviewed for infection control: 5
Date of incident: May 2, 2025
Date of CNA termination: May 5, 2025
Date of staff in-service training: May 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nursing Assistant | Admitted to transferring Resident #107 alone in violation of care plan; terminated following investigation |
| LPN #4 | Licensed Practical Nurse | Assessed Resident #107 after injury and confirmed CNA #3's admission |
| Assistant Director of Nursing | Assistant Director of Nursing | Confirmed CNA #3 transferred Resident #107 alone; verified staff training on mechanical lifts |
| Director of Nursing | Director of Nursing | Verified staff training on mechanical lifts and infection control practices; confirmed PPE requirements |
| Administrator | Administrator | Confirmed CNA #3's admission and termination; verified PPE stocking and monitoring |
| RN #1 | Registered Nurse | Observed performing trach care without appropriate PPE |
| RN #2 | Registered Nurse | Observed touching medication bare handed and administering medication without gown; confirmed PPE requirements |
| Infection Preventionist | Infection Preventionist | Verified PPE use requirements and staff competency checks |
| CNA #15 | Certified Nursing Assistant | Stated EBP was implemented to protect residents with open sites |
Inspection Report
Routine
Deficiencies: 1
Date: Sep 18, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with infection prevention and control practices, specifically regarding the implementation of Enhanced Barrier Precautions (EBP) for residents requiring such precautions.
Findings
The facility failed to ensure staff consistently used appropriate personal protective equipment (PPE) when providing care to residents on Enhanced Barrier Precautions, including improper handling of medication without gloves and failure to wear gowns and masks during tracheostomy care. Multiple staff interviews and observations confirmed these lapses despite in-service training and policies in place.
Deficiencies (1)
Failure to implement infection control practices in accordance with Enhanced Barrier Precautions for residents requiring PPE, including not wearing gowns during medication administration and trach care, and touching medication bare handed.
Report Facts
Residents reviewed for infection control: 5
Residents reviewed for trach care: 1
Date of admission for Resident #1: May 11, 2024
Date of EBP intervention start: May 23, 2024
Date of EBP order for Resident #2: Apr 11, 2024
Date of medication administration in-service: Nov 18, 2024
Date of facility policy on Enhanced Barrier Precautions: Apr 20, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Observed not wearing gown during medication administration and acknowledged the error |
| RN #1 | Registered Nurse | Observed performing trach care without gown or mask and acknowledged the need for PPE |
| ADON | Assistant Director of Nursing | Verified PPE requirements and staff training on Enhanced Barrier Precautions |
| DON | Director of Nursing | Verified PPE requirements and in-services on EBP and medication administration |
| Administrator | Administrator | Verified PPE supply and monitoring of staff compliance |
| IP | Infection Preventionist | Verified PPE requirements, staff observations, and competency checks |
| CNA #15 | Certified Nursing Assistant | Stated EBP was put in place to protect residents with open sites |
Inspection Report
Routine
Deficiencies: 2
Date: Sep 18, 2025
Visit Reason
The inspection was conducted to assess compliance with nursing home regulations, focusing on accident prevention and infection control practices, including adherence to mechanical lift procedures and Enhanced Barrier Precautions (EBP).
Findings
The facility failed to ensure safe transfer procedures for one resident, resulting in actual harm due to staff transferring the resident alone against care plan requirements. Additionally, the facility did not consistently implement infection control practices, including proper use of PPE during medication administration and tracheostomy care, placing residents at risk of infection.
Deficiencies (2)
Failure to ensure safe transfer procedures using a mechanical lift with two-person assistance, resulting in injury to Resident #107.
Failure to implement infection control practices in accordance with Enhanced Barrier Precautions (EBP) for residents requiring PPE, including improper use of gloves, gowns, and masks during medication administration and tracheostomy care.
Report Facts
Residents reviewed for accidents and supervision: 8
Residents reviewed for infection control: 5
Residents reviewed for trach care: 1
Date of incident: May 2, 2025
Date of CNA termination: May 5, 2025
Date of staff in-service completion: May 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nursing Assistant | Admitted to transferring Resident #107 alone, violating care plan; terminated following investigation |
| LPN #4 | Licensed Practical Nurse | Assessed Resident #107 after incident, confirmed CNA #3's admission, suspended CNA #3 pending investigation |
| Assistant Director of Nursing | Assistant Director of Nursing | Confirmed CNA #3 transferred resident alone; verified staff training on mechanical lifts and infection control |
| Director of Nursing | Director of Nursing | Verified staff training and supervision; confirmed infection control practices and PPE requirements |
| Administrator | Administrator | Confirmed CNA #3's admission and termination; verified PPE stocking and monitoring of infection control compliance |
| RN #1 | Registered Nurse | Observed performing trach care without proper PPE; acknowledged need for gown during procedure |
| RN #2 | Registered Nurse | Observed touching medication bare handed and administering medication without gown; confirmed PPE requirements |
| CNA #15 | Certified Nursing Assistant | Stated EBP was put in place to protect residents with open sites on the body |
| Infection Preventionist | Infection Preventionist | Verified PPE competency checks and staff observations to ensure compliance with EBP |
Inspection Report
Routine
Deficiencies: 1
Date: Sep 18, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control practices, specifically regarding the implementation of Enhanced Barrier Precautions (EBP) for residents requiring such precautions.
Findings
The facility failed to ensure staff consistently implemented infection control practices in accordance with EBP requirements for two residents reviewed, including failure to wear appropriate personal protective equipment (PPE) during medication administration and tracheostomy care. Multiple staff interviews and observations confirmed non-compliance with PPE protocols.
Deficiencies (1)
Failure to implement infection control practices in accordance with Enhanced Barrier Precautions (EBP) for residents requiring such precautions, including not wearing gowns and gloves during medication administration and trach care.
Report Facts
Residents reviewed for infection control: 5
Residents reviewed for trach care: 1
Date of admission for Resident #1: May 11, 2024
Date of EBP order for Resident #2: Apr 11, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed performing trach care without appropriate PPE and acknowledged EBP importance |
| RN #2 | Registered Nurse | Observed administering medication without gown or gloves and acknowledged PPE requirements |
| ADON | Assistant Director of Nursing | Verified PPE requirements and infection control practices during interviews |
| DON | Director of Nursing | Verified PPE requirements and infection control practices during interviews |
| Administrator | Administrator | Verified PPE supply and monitoring of staff compliance |
| IP | Infection Preventionist | Verified PPE requirements and staff competency checks |
| CNA #15 | Certified Nursing Assistant | Provided information on EBP purpose during interview |
Inspection Report
Routine
Deficiencies: 9
Date: May 31, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations at Woodruff County Health Center.
Findings
The facility was found deficient in multiple areas including failure to keep call lights within reach of residents, inaccurate Minimum Data Set (MDS) assessments, incomplete care plans, inadequate assistance with activities of daily living such as nail and foot care, improper storage of chemicals and open drinks accessible to residents, improper catheter bag placement, and failure to prepare pureed food to the correct consistency.
Deficiencies (9)
Failed to ensure call light was kept within reach for Resident #23.
Failed to complete an accurate Minimum Data Set (MDS) for Resident #48 regarding chair alarm use.
Failed to revise individualized plan of care to include chair alarm for Resident #48.
Failed to provide necessary assistance with fingernail care for Resident #85.
Failed to provide necessary foot care including toenail trimming for Resident #74.
Failed to ensure chemicals were stored out of reach of residents on the 500 Hall.
Failed to ensure catheter bag was positioned below the bladder for Resident #81.
Failed to ensure pureed food was processed to the correct consistency for 4 residents.
Failed to ensure an open drink was not left within reach of residents on the 500 Hall.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Pureed residents affected: 4
Assessment Reference Dates: Apr 19, 2024
Assessment Reference Dates: Apr 15, 2024
Assessment Reference Dates: Apr 2, 2024
Assessment Reference Dates: Apr 3, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Confirmed call light should be in reach for Resident #23 and described catheter care |
| Certified Nurse Assistant #8 | Certified Nurse Assistant | Confirmed call light policy and Resident #23's fall history |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Confirmed Resident #48 uses chair alarm and was not care planned for it |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Confirmed Resident #48 uses chair alarm and was not care planned for it |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Described Resident #85's fingernail condition and catheter bag placement |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Described Resident #74's toenail condition and chemical storage concerns |
| Certified Nursing Assistant #7 | Certified Nursing Assistant | Described Resident #74's toenail condition and foot care process |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Confirmed chemicals and open drink should not be stored on linen cart |
| Certified Nursing Assistant #9 | Certified Nursing Assistant | Observed pureed food serving and described consistency |
| Dietary Aide #11 | Dietary Aide | Prepared pureed food inconsistently with too thin consistency |
| Dietary Manager | Dietary Manager | Described pureed food as sloppy and too thin |
| Director of Nursing | Director of Nursing | Discussed catheter bag anti-reflux valve and supply |
| Infection Preventionist | Infection Preventionist | Confirmed open drink on linen cart is infection risk |
Inspection Report
Routine
Deficiencies: 9
Date: May 31, 2024
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations at Woodruff County Health Center.
Findings
The facility was found deficient in multiple areas including failure to keep call lights within reach of residents, inaccurate resident assessments, incomplete care plans, inadequate assistance with activities of daily living and hygiene, improper foot care, unsafe storage of chemicals, improper catheter care, improperly prepared pureed food, and infection control lapses such as leaving open drinks within residents' reach.
Deficiencies (9)
Failed to ensure call light was kept within reach for Resident #23.
Failed to complete an accurate Minimum Data Set (MDS) for Resident #48 regarding chair alarm use.
Failed to revise individualized plan of care to include chair alarm for Resident #48.
Failed to provide necessary assistance with activities of daily living, resulting in Resident #85 having long, dirty fingernails.
Failed to provide appropriate foot care for Resident #74, resulting in thick, yellow, ingrown toenails and cracked skin.
Failed to ensure chemicals were stored out of residents' reach on the 500 Hall.
Failed to ensure catheter bag was positioned below the bladder for Resident #81.
Failed to ensure pureed food was processed to correct consistency for 4 residents, resulting in watery, sloppy food.
Failed to ensure an open drink was not left within reach of residents on the 500 Hall.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Pureed residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Confirmed call light should be in reach for Resident #23 and described catheter care |
| Certified Nurse Assistant #8 | Certified Nurse Assistant | Confirmed call light policy and Resident #23's fall history |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Confirmed Resident #48 uses chair alarm and was not care planned for it |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Confirmed Resident #48 uses chair alarm and was not care planned for it |
| MDS Coordinator | Confirmed Resident #48's MDS was inaccurate and care plan was incomplete | |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Described Resident #85's fingernail condition and catheter bag placement |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Described Resident #74's toenail condition and catheter bag placement |
| Certified Nursing Assistant #7 | Certified Nursing Assistant | Described Resident #74's toenail condition and foot care process |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Confirmed chemicals and open drinks should not be stored on linen cart |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Confirmed chemicals should not be stored on linen cart |
| Certified Nursing Assistant #9 | Certified Nursing Assistant | Observed pureed food consistency and described difficulty feeding residents |
| Dietary Aide #11 | Dietary Aide | Prepared pureed food inconsistently with too thin consistency |
| Dietary Manager | Dietary Manager | Described pureed food as sloppy and too thin |
| Infection Preventionist | Confirmed open drinks should not be left within residents' reach | |
| Director of Nursing | Director of Nursing | Provided information on catheter bags and anti-reflux valves |
Inspection Report
Routine
Census: 84
Deficiencies: 5
Date: Mar 10, 2023
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in several areas including failure to provide timely and adequate transfer/discharge notifications, incomplete baseline care plans regarding oxygen therapy, improper respiratory care practices, inadequate preparation and consistency of pureed foods, and poor food storage and handling practices in the kitchen.
Deficiencies (5)
Failure to provide timely notification to resident and representative before transfer or discharge, including appeal rights.
Failure to accurately complete a Baseline Care Plan to reflect the use of oxygen therapy for a resident.
Failure to ensure oxygen tubing was changed, dated, and stored properly; suction catheter and tubing were not dated or stored properly; nebulizer masks were not changed and dated as required.
Failure to ensure pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets.
Failure to ensure foods stored in freezer, refrigerator, and dry storage were covered, sealed, and dated; failure to discard expired food items; failure of dietary staff to wash hands before handling food; failure to maintain cold food at or below 41 degrees Fahrenheit.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 8
Residents affected: 79
Total census: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding transfer/discharge documentation and respiratory care practices | |
| Social Director | Provided transfer documents and discussed Baseline Care Plan completion | |
| Administrator | Discussed transfer notification form and facility policies | |
| Director of Nursing (DON) | Interviewed about importance of oxygen therapy in care plans and respiratory care procedures | |
| MDS Coordinator | Interviewed about Baseline Care Plan completion | |
| Licensed Practical Nurse (LPN) #2 | Interviewed about oxygen tubing and humidifier bottle change frequency | |
| Dietary Employee #1 | Observed handling food and food temperature | |
| Dietary Employee #2 | Interviewed about pureed food consistency | |
| Dietary Supervisor | Interviewed about food storage, leftover food use, and hand washing policy | |
| Certified Nursing Assistants (CNA) #1 through #6 | Interviewed about consistency of pureed foods served |
Inspection Report
Routine
Census: 84
Deficiencies: 5
Date: Mar 10, 2023
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations at Woodruff County Health Center.
Findings
The facility was found deficient in multiple areas including failure to provide timely and proper notification of resident transfers, incomplete baseline care plans regarding oxygen therapy, improper respiratory care practices, inadequate preparation of pureed foods, and poor food storage and handling practices in the kitchen. These deficiencies posed minimal to potential harm risks to residents.
Deficiencies (5)
Failed to provide timely notification to resident and representative of transfer reason in writing in a language they could understand.
Failed to accurately complete a Baseline Care Plan to reflect oxygen therapy use for a resident.
Failed to ensure oxygen tubing was changed, dated, and stored properly; suction catheter and tubing were not dated or bagged; nebulizer masks were not changed and dated as required.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets.
Failed to ensure foods stored in freezer, refrigerator, and dry storage were covered, sealed, and dated; failed to discard expired food; dietary staff failed to wash hands before handling food; cold food was not maintained at or below 41°F.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 8
Total census: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding transfer documentation and respiratory care practices | |
| Social Director | Provided transfer documents and discussed baseline care plan completion | |
| Administrator | Interviewed regarding transfer notice form and facility policies | |
| Director of Nursing (DON) | Interviewed regarding importance of oxygen therapy in care plans and respiratory care procedures | |
| MDS Coordinator | Interviewed regarding baseline care plan completion | |
| Licensed Practical Nurse (LPN) #2 | Interviewed regarding oxygen tubing change frequency | |
| Dietary Employee #1 | Observed handling food and food temperature | |
| Dietary Employee #2 | Interviewed and observed regarding pureed food consistency | |
| Dietary Supervisor | Interviewed regarding food storage, leftover food use, and handwashing policy | |
| Certified Nursing Assistants (CNA) #1 to #6 | Interviewed regarding consistency of pureed foods served |
Viewing
Loading inspection reports...
