Woodruff County Health Center: Accident Harm Cited - AR
CNA #3 admitted during a September interview that she knowingly violated both the resident's care plan and facility policy when she transferred Resident #107 without assistance. The worker had been hired just eight months earlier in September 2024 and received training on lift transfers three days after starting.
"CNA #3 admitted to being aware all residents requiring a lift to transfer in this facility required two staff persons yet knowingly transferred Resident #107 independently," inspectors wrote.
The transfer resulted in skin tears on the resident. The facility's Director of Nursing told investigators the injuries likely occurred from improper placement of the lift pad during the solo transfer. Other staff members were available at the time, but CNA #3 never requested help.
Resident #107's care plan specifically required two staff members for all transfers using the mechanical lift. The facility's Safe Lifting of Residents policy, last updated in December 2013, states that resident safety, dignity, comfort and medical condition must guide all decisions about lifting and moving residents.
The Administrator confirmed during a September 18th interview that CNA #3 had admitted to the solo transfer. Following the facility's internal investigation, the nursing assistant was terminated on May 5th, three days after the incident.
But the violation went undetected by state inspectors until they arrived in September to investigate a complaint. The inspection report doesn't indicate who filed the complaint or when, leaving a four-month gap between the injury and regulatory discovery.
CNA #3 told investigators she understood the two-person requirement applied to all residents needing lift assistance at the facility. The worker had completed in-service training on proper lift transfers on September 5, 2024, just days after being hired.
The facility responded to the incident by conducting facility-wide retraining on safe transfer procedures. All staff completed the additional training by May 12th, a week after CNA #3's termination. Interviews with remaining staff confirmed they understood the training requirements.
Federal inspectors classified the violation as causing "actual harm" to residents, with "few" residents affected. The finding falls under federal regulations requiring nursing homes to ensure residents receive treatment and care that prevents accidents and maintains the highest practicable physical, mental and psychosocial well-being.
Mechanical lift transfers require precise coordination between two staff members. One typically operates the lift controls while the other guides and supports the resident during movement. The lift pad must be positioned correctly under the resident before lifting begins, and both workers monitor the resident's position throughout the transfer.
Improper lift pad placement can cause the fabric to bunch or twist against the resident's skin during lifting. When combined with the resident's full body weight pressing against the pad, this creates conditions for skin tears, particularly among elderly residents with fragile skin.
The September inspection focused specifically on this transfer incident. Investigators interviewed the Administrator, Director of Nursing, and the terminated nursing assistant to reconstruct what happened during the May 2nd transfer.
CNA #3's admission that she knowingly violated policy while other staff remained available raises questions about supervision and accountability at the 139 West Highway 64 facility. The worker continued providing resident care for three additional days after injuring Resident #107 before the investigation concluded.
The facility's response included immediate termination and comprehensive retraining, but the four-month delay before regulatory discovery suggests the incident might have remained internal without the September complaint that triggered the inspection.
Resident #107's current condition and the extent of medical treatment required for the skin tears remain unclear from the available inspection documentation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodruff County Health Center from 2025-09-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
WOODRUFF COUNTY HEALTH CENTER in MCCRORY, AR was cited for violations during a health inspection on September 18, 2025.
The worker had been hired just eight months earlier in September 2024 and received training on lift transfers three days after starting.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.