Woodruff County Health Center

F 0689

available at the time of the incident and that CNA #3 did not request assistance. The DON indicated the skin tears may have resulted from improper placement of the lift pad during the transfer.

Level of Harm - Actual harm Residents Affected - Few

During an interview on 09/18/2025 at 12:01 PM, the Administrator confirmed that CNA #3 admitted to transferring Resident #107 alone. The Administrator stated that CNA #3 was terminated following the outcome of the investigation.

During an interview on 09/18/2025 at 1:09 PM, CNA #3, who was hired on at the facility on 9/02/2024 and in-serviced on lift transfers on 9/05/2024, indicated she had transferred Resident #107 without a second staff member, in violation of the care plan and facility policy. 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. CNA #3 stated the transfer conducted on 05/02/2025, resulted in the termination of her employment following the facility investigation.

Review of a facility policy titled Safe Lifting of Residents, revised 12/01/2013, indicated that resident safety, dignity, comfort, and medical condition would be incorporated into decisions regarding lifting and moving residents.

This failure to follow safe transfer procedures placed Resident #107 at risk for injury and resulted in actual harm.

Review of facility documentation revealed CNA #3 had been terminated on 05/05/2025 following the facility's investigation, and that all staff had been in-serviced following the event, completed 05/12/2025.

Interviews with staff verified understanding of the training.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodruff County Health Center

139 West Highway 64 McCrory, AR 72101

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

During an interview on 09/18/2025, at 11:25 AM, the DON stated that PPE should be donned outside the resident's room and that staff are required to wear gown, gloves, and mask when providing care to residents on EBP. The DON stated that EBP was used to prevent infections and rehospitalizations and that in-services were conducted to educate staff on EBP practices.

During an interview on 09/18/2025, at 11:55 AM, the Administrator stated that PPE was stocked outside the rooms of residents on EBP and that charts were flagged to identify residents who require EBP. The Administrator stated that supervisors monitor staff compliance and that camera footage was reviewed to ensure adherence to infection control practices.

During an interview on 09/18/2025, at 2:45 PM, the IP stated that trach care required a gown, gloves, and mask under EBP. The IP stated that staff were observed daily and received annual PPE competency checks to ensure proper donning and doffing procedures.

A review of a Medication Administration in-service, dated 11/18/2024, indicated Do not touch oral medication.

A review of a facility policy titled, Personal Protective Equipment, dated 09/2010, indicated When to use a mask: when performing a task that may involve the splashing of blood or body fluids into the mouth or nose.

Gowns- Use gowns only when indicated or as instructed. When use of a gown is indicated, all personnel must put on the gown before treating or touching the resident.

A review of the facility's undated policy titled, Tracheostomy Care, indicated, Put exam gloves on both hands; masks and eye wear should be worn if there is a likelihood of splashes and splattering.

A review of a facility policy titled, Enhanced Barrier Precautions, dated 04/20/2024, revealed, it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. High-contact resident care activities include device care or use of feeding tubes and tracheostomy/ventilator tube.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet