Woodruff County Health Center: Infection Control Gaps - AR
CNA #3 admitted during a September interview that she knowingly violated both the resident's care plan and facility policy when she performed the transfer without a second staff member present. The aide had been hired just eight months earlier, on September 2, 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," federal inspectors wrote in their September 18 complaint investigation report.
The violation resulted in actual harm to the resident, according to the Centers for Medicare and Medicaid Services inspection. The Director of Nursing told investigators that skin tears may have resulted from improper placement of the lift pad during the unauthorized solo transfer.
Woodruff County Health Center's Administrator confirmed that CNA #3 admitted to transferring Resident #107 alone. The facility launched an investigation immediately after the incident and terminated the aide on May 5, three days after the transfer occurred.
The nursing assistant's actions directly contradicted facility policy and her recent training. She had completed in-service training on lift transfers on September 5, 2024, just days after being hired. During her September interview with inspectors, she acknowledged understanding that all residents requiring mechanical lifts needed two staff members for safe transfers.
The facility's Safe Lifting of Residents policy, last revised in December 2013, requires that "resident safety, dignity, comfort, and medical condition would be incorporated into decisions regarding lifting and moving residents." Federal inspectors determined that CNA #3's failure to follow these procedures placed Resident #107 at risk for injury.
The Director of Nursing explained to investigators that other staff members were available at the time of the incident, meaning CNA #3 could have requested assistance but chose not to. This decision violated both the specific resident's care plan requirements and the facility's universal policy requiring two-person transfers for all lift-dependent residents.
Following the incident and subsequent investigation, Woodruff County Health Center conducted facility-wide retraining on safe transfer procedures. All staff completed the mandatory in-service training by May 12, 2025, one week after the aide's termination.
Inspectors interviewed multiple staff members to verify their understanding of the updated training. The interviews confirmed that employees understood the requirements for safe resident transfers using mechanical lifts.
The violation falls under federal regulations governing accident prevention and safe transfer procedures in nursing homes. CMS classified the deficiency as causing "actual harm" to "few" residents, indicating the incident affected a small number of people but resulted in documented injury.
Mechanical lift transfers require precise coordination between two trained staff members to ensure resident safety. One person typically operates the lift controls while the other guides and supports the resident during movement. The two-person requirement exists specifically to prevent injuries like skin tears, falls, and other transfer-related harm.
The timing of the incident, occurring eight months after the aide's hire date and training, suggests the violation was not due to inexperience or lack of knowledge. CNA #3's admission that she was aware of the two-person requirement but chose to proceed alone indicates a deliberate policy violation rather than a training failure.
The facility's swift response, including immediate investigation, termination within three days, and comprehensive staff retraining within a week, demonstrates recognition of the serious safety breach. However, the incident highlights ongoing challenges in ensuring consistent adherence to safety protocols in nursing home settings.
Resident #107's skin tears represent the type of preventable injury that federal regulations are designed to avoid. The incident occurred despite clear policies, recent training, and available staff assistance, underscoring the critical importance of individual accountability in resident safety protocols.
The complaint investigation concluded that the facility's failure to ensure safe transfer procedures placed residents at risk and resulted in actual harm to at least one person under their care.
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 20, 2026 · Our methodology
WOODRUFF COUNTY HEALTH CENTER in MCCRORY, AR was cited for violations during a health inspection on September 18, 2025.
The aide had been hired just eight months earlier, on September 2, 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.