summary: Complaint #(AR00033420) was not in compliance. Complaint #(AR00034831) was not in compliance. Complaint #(AR00034929) was not in compliance.

raw_content:
Division of Provider Services
& Quality Assurance
P.O. Box 8059, Slot S404
Little Rock, AR 72203-8059
September 16, 2024
Derek Thompson, Administrator
Woodridge Of The Ozarks
2466 S 48th Street
Springdale, AR 72762
Dear Mr. Thompson:
On August 30, 2024 a Complaint Investigation survey was conducted at your facility by the Office of
Long Term Care to determine if your facility was in compliance with Federal requirements for
Psychiatric Residential Treatment Facilities participating in the Medicaid (Title XIX) Program. This
survey found that your facility had deficiencies requiring correction/substantial correction prior to a
revisit as specified in the attached CMS-2567.
Plan of Correction
A POC must be submitted within 10 calendar days of you receipt of the Statement of
Deficiencies. Failure to submit a POC may result in termination. Include a completion date for each
deficieny cited.
Robyn Cornelius, Reviewer
OLTC, Survey & Certification Section
PO Box 8059, Slot S404
Little Rock, AR 72201-4608
(501) 320-3945
email to robyn.l.cornelius@dhs.arkansas.gov.
Your Plan of Correction must also include the following:
a. Address how the corrective action will be accomplished for those residents found to have been
affected by the deficient practice;
b. Address how the facility will identify other residents having the potential to be affected by the same
deficient practice;
c. Address what measures will be put into place or systemic changes will be made to ensure that the
deficient practice will not recur;
d. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.
The facility must develop plan for ensuring that correction is achieved and sustained. This plan must
be implemented, and the corrective action evaluated for its effectiveness.
Derek Thompson - Woodridge Of The Ozarks - - (AOLTC - PRTF OTC) Page 1]

e. Include dates when corrective action will be completed. The corrective action completion dates must
be acceptable to the State. Your facility is ultimately accountable for its own compliance. The plan of
correction will serve as the facility’s allegation of compliance. Unless otherwise stated on the PoC, the
last completion date will be the date of alleged compliance.
Informal Dispute Resolution
In accordance with 42 CFR § 488.331, you have one opportunity to question deficiencies through an
informal dispute resolution (IDR) process. To obtain an IDR, you must send your written request to
Health Facility Services, Arkansas Department of Health within ten (10) calendar days from receipt of
the Statement of Deficiencies. The request must state the specific deficiencies the facility wishes to
challenge. The request should also state whether the facility wants the IDR to be performed by a
telephone conference call, record review, or a face-to-face meeting.
An incomplete informal dispute resolution procedure will not delay the effective date of any
enforcement action or the requirement for timely submission of an acceptable plan of correction.
Informal dispute resolution in no way is to be construed as a formal evidentiary hearing. It is an
informal administrative process to discuss the findings.
Please submit your request to:
IDR/IIDR Program Coordinator
Health Facilities Services
5800 West 10th Street, Suite 400
Little Rock, AR 72204
Phone: 501-661-2201
ADH.HFS@Arkansas.gov
If you have any questions, please contact your Reviewer.
Sincerely,
for Jeff Rosenbaum
DPSQA/Office of Long Term Care
Survey & Certification Section
rc
cc: DRA
Derek Thompson - Woodridge Of The Ozarks - - (AOLTC - PRTF OTC) Page 2]

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 000 Initial Comments N 000
Note: The CMS-2567 (Statement of Deficiencies)
is an official, legal document. All information must
remain unchanged except for entering the plan of
correction, correction dates, and the signature
space. Any discrepancy in the original deficiency
citation(s) will be reported to the Dallas Regional
Office (RO) for referral to the Office of the
Inspector General (OIG) for possible fraud. If
information is inadvertently changed by the
provider/supplier, the State Survey Agency (SA)
should be notified immediately.
Complaint #(AR00033420) was not in
compliance, all or in part, with deficiency cited at
N127, N142, N144, N145, N148, N149, N151,
N152, N153, N154, N156, N178, N179, N188,
N189, N193
Complaint #(AR00034831) was not in
compliance, all or in part, with deficiency cited at
N127, N128, N142, N144, N145, N148, N149,
N151, N152, N153, N154, N156, N178, N179,
N188, N189, and N193
Complaint #(AR00034929) was not in
compliance, all or in part, with deficiency cited at
N127, N144, N145, N148, N149, N151, N152,
N153, N154, N156, N188, N189, and N193
The facility was not in compliance with §483,
Subpart G - Conditions of Participation for
Psychiatric Residential Treatment Center.
N 126 PROTECTION OF RESIDENTS N 126
CFR(s): 483.356 (a)(1)
Each resident has the right to be free from
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 1 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 126 Continued From page 1 N 126
restraint or seclusion, of any form, used as a
means of coercion, discipline, convenience, or
retaliation.
This ELEMENT is not met as evidenced by:
Based on observation, interview and record
review, the facility failed to ensure Client #1 was
free from chemical restraint.
The findings are:
Review of a psychiatric progress note dated
"06/22/24", revealed Client #1 had diagnoses
including borderline intellectual function,
disruptive mood dysregulation disorder, and
history of abuse.
The following is a review of facility video footage
of 06/22/24.
At approximately 9:15 AM, Client #1 walked into
the seclusion room alone and went to the corner
under the video camera, Client #1 was not visible
for the rest of the video footage due to the
position of camera. At approximately 9:35 AM, via
video in hallway footage, two male staff members
were seen dragging Client #1 from the seclusion
room holding the client under both arms, two
female staff members were following. Video
footage from the day room revealed at 9:36 AM
Client #1 being taken into the day room before
trying to return through the doors pushing at and
striking at staff when staff continued to take client
into the day room. Additional clients began to
push and hit at staff and Client#1. Staff separated
the clients and Client #1 was escorted to a chair
and sat down at 9:36 AM.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 2 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 126 Continued From page 2 N 126
Client #1's lower body was visible from the
camera angle, except for head and shoulders.
Client #1 continued to sit in the same position.
Another client approached and threw a cup of
water at Client #1, to which Client #1 did not
physically react. The cup laid on Client's lap until
9:44 AM when Client #1's right knee began to
bounce up and down slightly causing the cup to
roll off his/her lap. Two male staff members
remained in dayroom talking and interacting with
other clients, no interaction were noted between
staff and Client #1.
At approximately 9:52 AM, three additional staff
members entered, approached Client #1, and
administered an injection. Client #1 remained
seated and began to rub his/her right thigh after
staff stepped away. Video footage was viewed
until 10:06 AM, at which Client #1 continued to sit
in the same chair.
On 08/26/24 at 3:36 PM, the Director of Risk
Management agreed that review of Client #1's
behavior revealed Client #1 was sitting quietly for
approximately 17 minutes and did not appear to
be in need of a chemical restraint.
A facility policy received on 08/26/2024 titled
"Restraint or Seclusion Use" with a revised date
of "01/2024" showed a restraint is any manual
method, physical or mechanical device, or a drug
used as a restriction to manage a client's
behavior, and that prior to using a restraint an
alternative method should be considered that is
less restrictive. and indicated the techniques
should never be used for punishment
N 127 PROTECTION OF RESIDENTS N 127
CFR(s): 483.356(a)(2)
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 3 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 127 Continued From page 3 N 127
An order for restraint or seclusion must not be
written as a standing order or on an as-needed
basis.
This ELEMENT is not met as evidenced by:
Based on interview and record review, the facility
failed to ensure physician's orders for a restraint
or seclusion were documented in the clients
record for 5 (Clients #1, #2, #5, #6, and #7) case
mix clients.
The findings are:
A review of the psychiatric discharge summary
dated 04/24/2024 revealed Client #5 had
diagnoses of attention deficit hyperactivity
disorder [ADHD], conduct disorder, oppositional
defiant disorder, and manic episode.
The emergency safety intervention justification
packets were reviewed for these dates, they
showed that Client #5 had physical, chemical
restraints, and/or seclusion administered on
04/11/2024 sat 1937 [7:37 PM] and 04/22/2024 at
1329 [1:29 PM] without a physician's order
documented or available in the clients record.
A review of the Psychiatric Progress note dated
07/24/2024 revealed Client #7 had a diagnoses of
disruptive mood dysregulation disorder and
ADHD.
The emergency safety intervention justification
packets were reviewed for this dates, they
showed that the Client #7 had physical or
chemical restraints and/or seclusion
documentation on 03/18/2024 at 1803 [6:03 PM],
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 4 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 127 Continued From page 4 N 127
04/01/2024 at 1420 [2:20 PM], 04/15/2024 at
1745 [5:45 PM], 05/02/2024 at 1309 [1:09 PM],
05/11/2024 at 0908 [9:08 AM] 07/14/2024 at 1647
[4:47 PM], 07/19/2024 at 1928 [7:28 PM] and
2058 [8:58 PM] without a physician's order
documented or available in the client's record.
A review of facility policy received on 08/26/2024
titled "Restraint or Seclusion Use," revised date of
"01/2024," showed restraint is any manual
method, physical or mechanical device, or a drug
used as a restriction to manage a clients
behavior. Seclusion is involuntary confinement
alone in a room or area and the client is
prevented from leaving. A least restrictive
measure is referred to as a consideration prior to
the use of medication. The order will be obtained
from the attending physician either during the
emergency, or immediately after the
implementation of restraint or seclusion.
On 8/28/2024 at 9:00 AM, during an interview
with the Director of Nursing [DON] and the
Director of Risk Management, both agreed
physician's orders were required for restraints or
seclusion. On 8/29/2024 at 11:42 AM, during an
interview with the Director of Risk Management,
she stated she was unable to find any of the
missing orders.
Review of a psychiatric progress note dated
06/22/24 revealed Client #1 had diagnoses
including borderline intellectual function,
disruptive mood dysregulation disorder, and
history of abuse.
Review of Client#1's medical record revealed a
nurse's note dated 06/12/24, and the facility's
restraint and seclusion log revealed Client #1 was
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 5 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 127 Continued From page 5 N 127
placed in a physical restraint from 7:47 PM to
8:08 PM on 06/12/2024. No physician order was
in the chart.
-Review of Client#1's chart revealed an
Emergency Safety Intervention packet dated
06/22/2024 revealed Client #1 was placed in
seclusion from 1:13 PM until 1:30 PM. No
physician order was in the chart.
Documents were requested from the Director of
Risk Management (DRM). On 08/26 at 3:36 PM,
the DRM reported she was unable to locate the
physician orders regarding the incidents.
Client #6 had a diagnosis of disruptive mood
dysregulation disorder.
Review of the facility's restraint and seclusion log
revealed on 06/16/2024, Client #6 was placed in
a physical restraint from 2:55 PM until 3:37 PM
and was given a chemical restraint at 3:11 PM.
No physician orders were in the chart.
N 128 PROTECTION OF RESIDENTS N 128
CFR(s): 483.356(a)(3)
Restraint or seclusion must not result in harm or
injury to the resident and must be used only-
This ELEMENT is not met as evidenced by:
Based on video review, interview, and record
review, the facility failed to ensure that client who
received emergency safety interventions didn't
receive potentially avoidable injuries for 3 (Clients
#2, #3 and #4) case mix clients who had
emergency safety interventions.
The findings are:
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 6 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 128 Continued From page 6 N 128
A review of the psychiatric progress note dated
08/14/2024 revealed Client #3 had diagnosis of
Disruptive Mood Dysregulation Disorder and
Conduct Disorder.
A review of the emergency safety intervention
justification packet dated 08/11/2024 at 1715
[5:15 PM] with a physical and chemical restraint
safety intervention implemented revealed Client
#3 received an injury due to improper technique
of the applied physical restraint. The emergency
safety intervention documentation was reviewed
and indicated client #3 had pain to the right side
of the head.
On 08/28/2024 at 11:03 AM the video
documentation of the incident was reviewed with
the Director of Risk Management. Client #3
during the video review of the emergency safety
intervention, it revealed client was pulled from the
melee at 5:21 PM and placed into a physical
restraint, then received a chemical restraint at
5:44 PM.
Client #3 was interviewed on 8/28/24 1:21 PM
and indicated an injury to the right side of the
head that occurred during the emergency safety
intervention.
On 8/29/2024 at 3:54 PM, an interview was
conducted with Registered Nurse [RN] #2, who
was asked if he felt the restraint had been applied
correctly. The RN #2 indicated feeling that the
restraint didn't follow the Handle with Care [HWC]
training provided by the facility. RN #2 indicated
during the debriefing there was a concern with
the level of force used against the client during
the implementation of the restraint.
Client #4 a review of the psychiatric progress note
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 7 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 128 Continued From page 7 N 128
dated 7/24/2024 revealed the client had
diagnoses of major depressive disorder
recurrent, severe, bulimia nervosa, and
post-traumatic stress disorder [PTSD].
Review of Client #4's 8.11 1700 ESI injury
document revealed the client had an emergency
safety intervention on 08/11/2024 at 1715 [5:15
PM] with a physical and chemical restraint
intervention implemented, the emergency safety
intervention documentation was reviewed and
indicated client #4 had a laceration on the lip, an
abrasion to the left shoulder and pain to the back
of the head and the right side of the head and
neck.
On 08/28/2024 at 11:03 AM the video
documentation of the incident was reviewed with
the Director of Risk Management. During video
review of the emergency safety intervention,
involving Client #4, it revealed client #4 was
placed into personal restraint at 5:20 PM, staff #3
was observed with the left forearm over the neck
of client #4. According to the Director of Risk
Management, this technique isn't part of the
"Handle With Care" program instructed at the
facility. This intervention, performed incorrectly,
resulted in an injury to the client's right side of the
head, shoulder, neck and lip.
On 8/29/2024 at 3:54 PM, an interview was
conducted with Registered Nurse [RN] #2. RN #2
who was holding the clients right arm indicated
staff #4 who was standing, "stomped" on client
#4's head and staff #3 was holding their arm on
the clients neck. RN #2 indicated the inability to
stop the action or say anything during the
restraint due to the event happening over a
matter of seconds. RN #2 reported his concerns
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 8 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 128 Continued From page 8 N 128
as soon as possible after the event to the DON
[director of nursing] and the Clinical Director.
-A facility policy received on 08/26/2024 titled
"Restraint or Seclusion Use" with a revised date
of 01/2024 showed a restraint is any manual
method, physical or mechanical device, or a drug
used as a restriction to manage a clients
behavior. Any signs of injury related to the
implementation of the emergency safety
intervention should be documented. (bottom and
mid page 7)
-The Handle with Care system manual, received
on 8/27/2024, was reviewed and indicated the
techniques should never be used for punishment.
The training addresses holding the shoulders
down, being sure to not put pressure on the chest
and to protect the head from injuries.
Review of The Master Treatment Plan dated,
"7/5/2024" revealed Client # 2 had diagnoses
including post-traumatic stress disorder,
oppositional defiant disorder, attention deficit
hyperactivity disorder, bipolar II disorder,
borderline intellectual functioning.
Review of the Emergency Safety Intervention
packet dated "8/11/2024" revealed Client #2 had
an emergency safety intervention on 08/11/2024
at 1715 [5:15 PM] with a physical and chemical
restraint intervention implemented. The
emergency safety intervention documentation
was reviewed and indicated Client #2 had a
bruise on the right inner forearm.
On 08/28/2024 at 1:40 PM, during an interview
Client #2 reported receiving a bruise on her/his
right inner forearm during the behavioral incident
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 9 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 128 Continued From page 9 N 128
on 08/11/2024.
N 141 ORDERS FOR USE OF RESTRAINT OR N 141
SECLUSION
CFR(s): 483.358(b)
If the resident's treatment team physician is
available, only he or she can order restraint or
seclusion.
This ELEMENT is not met as evidenced by:
Based on interviews and record review the
facility failed to ensure a physician's order for
restraints and seclusion was obtained for Clients
#1 and #2.
The findings are:
Review of a psychiatric progress note dated,
"06/22/24" revealed Client #1 had diagnoses
including borderline intellectual function,
disruptive mood dysregulation disorder, and
history of abuse.
Review of the facility's restraint / seclusion log
and nurse's note dated 6/12/24 revealed Client #1
was placed in a physical restraint from 7:47 PM to
8:08 PM. No physician order or Emergency
Safety Intervention Justification Packet (ESI)
were in the chart.
Review of the facility's restraint and seclusion log
and Emergency Safety Intervention Justification
packet dated 6/22/24, revealed Client #1 was
placed in seclusion at 1:13 PM until 1:30 PM. No
physician orders were in the chart.
Physician orders and ESI documents were
requested from the Director of Risk Management
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 10 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 141 Continued From page 10 N 141
(DRM). At 3:36 PM, the DRM reported she was
unable to locate the ESI or physician orders
regarding the incidents.
Review of the Master Treatment Plan dated,
"7/5/2024" indicated Client # 2 had diagnoses
including post-traumatic stress disorder,
oppositional defiant disorder, attention deficit
hyperactivity disorder, bipolar II disorder,
borderline intellectual functioning.
Review of the facility's restraint and seclusion log,
ESI, and nurse's note dated 8/11/24 at 5:17 and
signed by Registered Nurse #1, revealed client
was placed in seclusion on 08/11/2024 at 5:18
PM and released at 5:55 PM. No physician orders
for seclusion were in the chart for 8/11/24
Review of ESI dated 08/13/2024 indicated client
was placed in a physical restraint at 9:57 AM,
released at 9:58 AM, and placed in seclusion at
9:59 AM. No physician orders for physical
restraint or seclusion for 8/13/24 were in the
chart.
On 08/27/24 at 11:50 AM, the Surveyor requested
all physician orders regarding Client #2 from the
DRM. At 12:50 PM, the DRM reported there were
no additional physician orders or ESI packets for
Client #2.
Review of a history and physical dated
"03/-7/2023" revealed Client #6 had diagnosis of
disruptive mood dysregulation disorder.
Review of the facility's restraint and seclusion log
revealed client was placed in seclusion on
06/11/2024 at 8:20 PM client was placed in a
physical hold and given a chemical restraint, no
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 11 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 141 Continued From page 11 N 141
physician orders for restraints were in the chart
for 6/11/24.
Review of a facility policy titled "Restraint or
Seclusion Use" revised 1/2024 revealed a
physician's order is to be obtained before a
restraint or seclusion is implemented or with a
few minutes of the restraint or seclusion.
N 142 ORDERS FOR USE OF RESTRAINT OR N 142
SECLUSION
CFR(s): 483.358(c)
A physician or other licensed practitioner
permitted by the state and the facility to order
restraint or seclusion must order the least
restrictive emergency safety intervention that is
most likely to be effective in resolving the
emergency safety situation based on consultation
with staff.
This ELEMENT is not met as evidenced by:
Based on interview and record review the facility
failed to ensure physician's orders for physical
and chemical restraints were not received at the
same time for 5 (Client #3, #4, #5, #6 and #7)
case mix clients.
A review of the psychiatric progress note dated
08/14/2024 revealed Client #3 had diagnosis of
disruptive mood dysregulation disorder and
conduct disorder.
Client #3's physician's orders dated:
-8/11/2024 1722 [5:22 PM] showed orders for
physical and chemical restraint.
-8/20/2024 received at 10:48 AM for physical and
chemical restraint.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 12 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 142 Continued From page 12 N 142
A review of the psychiatric progress note dated
7/24/2024 revealed Client #4 had diagnosis of
major depressive disorder, bulimia nervosa, and
post-traumatic stress disorder [PTSD].
Client #4 physician's orders showed the following:
-6/8/2024 1353 [1:53 PM] for physical and
chemical restraints.
-6/10/2024 0908 [9:08 AM] for physical and
chemical restraints.
A review of the psychiatric discharge summary
dated 04/24/2024 revealed Client #5 had
diagnosis of attention deficit hyperactivity disorder
[ADHD], conduct disorder, oppositional defiant
disorder, and manic episode.
Client #5's physician's orders showed the
following:
-03/15/2024 1029 [10:29 AM] for physical and
chemical restraints.
-03/28/2024 1548 [3:48 PM] for physical and
chemical restraints.
-04/05/2024 2122 [9:22 PM] for physical and
chemical restraints.
-04/22/2024 1900 [7:00 PM] for physical and
chemical restraints.
A review of the Psychiatric Progress note dated
07/24/2024 revealed Client #7 had diagnosis of
Disruptive Mood Dysregulation Disorder and
Attention-Deficit/Hyperactivity Disorder: (ADHD).
Client #7's physician's orders showed the
following:
-01/18/2024 at 1332 [1:32 PM] physical and
chemical restraint.
-03/6/2024 at 1802 [6:02 PM] physical and
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 13 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 142 Continued From page 13 N 142
chemical restraint.
-03/18/2024 at 1821 [6:21 PM] for physical and
chemical restraint.
-04/09/2024 at 0829 [8:29 AM] for physical
restraint and seclusion.
-04/13/2024 at 1011 [10:11 AM] for chemical
restraint and seclusion.
On 8/28/2024 at 9:00 AM, during an interview the
Director of Nurses [DON] and the Director of Risk
Management, agreed the orders should not be
obtained at the same time and the physician
should have signed the orders in a timely
manner.
A facility policy received and reviewed on
08/26/2024 titled "Restraint or Seclusion Use"
with a revised date of "01/2024" showed a
restraint is any manual method, physical or
mechanical device, or a drug used as a restriction
to manage a clients behavior. Seclusion is
involuntary confinement alone in a room or area
and the client is prevented from leaving. The
policy did not address physician's orders received
at the same time.
Review of a medical history and physical dated
"03/07/2023" revealed Client #6 had a diagnosis
of disruptive mood dysregulation disorder.
Review of the facility's restraint and seclusion log,
and emergency safety intervention documents
revealed Client #6 had the following
restraint/seclusion events:
On 03/25/24 Client #6 had a physical restraint
from 1:18 PM until 1:31 PM and a chemical
restraint at 1:26 PM, both physician orders were
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 14 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 142 Continued From page 14 N 142
dated and timed 03/25/24 at 1:25 PM.
On 04/26/24 client #6 had a physical restraint
documented from 5:12 PM until 5:30 PM and
chemical restraint at 5:27 PM with both physician
orders dated and timed 04/26/24 at 5:24 PM.
N 144 ORDERS FOR USE OF RESTRAINT OR N 144
SECLUSION
CFR(s): 483.358(e)
Each order for restraint or seclusion must:
(1) Be limited to no longer than the duration of
the emergency safety situation; and
(2) Under no circumstances exceed 4 hours for
residents ages 18 to 21; 2 hours for residents
ages 9 to 17; or 1 hour for residents under age
9.
This ELEMENT is not met as evidenced by:
Based on interview and record review, the facility
failed to ensure that an emergency safety
intervention justification packet was completed to
ensure that the duration of the safety intervention
was documented for 5 (Client #1, #4, #5, #6, and
#7) case mix clients who had emergency safety
interventions.
The findings are:
A review of the psychiatric progress note dated
7/24/2024 revealed that Client #4 had diagnoses
of major depressive disorder recurrent, severe,
bulimia nervosa, and post-traumatic stress
disorder [PTSD].
A review of the physician's orders revealed Client
#4 had emergency safety interventions on
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 15 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 144 Continued From page 15 N 144
06/10/2024 at 1043 [10:43 AM], 06/11/2024 at
1715 [5:15 PM] and 06/12/2024 at 1015 [10:15
AM]. When the emergency safety intervention
justification packet(s) were requested from the
Director of Risk Management, the director
confirmed they were not available for the clients
records. No Emergency Safety Intervention
Justification packet(s) were completed for these
dates to document the duration of the restraint or
seclusion.
A review of the psychiatric discharge summary for
Client #5 dated 04/24/2024 revealed client had
diagnoses of attention deficit hyperactivity
disorder [ADHD], combined presentation, conduct
disorder, oppositional defiant disorder, and manic
episode.
A review of the physician's orders revealed Client
#5 had emergency safety interventions on
03/06/2024 at 1530 [3:30 PM], 04/05/2024 at
2122 [9:22 PM], 04/17/2024 at 1336 [1:36 PM].
When the emergency safety intervention
justification packet(s) were requested from the
Director of Risk Management, the director
confirmed they were not available for the clients
records. No Emergency Safety Intervention
Justification packet(s) were completed for these
dates to document the duration of the restraint or
seclusion.
A review of the Psychiatric Progress note dated
07/24/2024 revealed Client #7 had diagnoses of
disruptive mood dysregulation disorder and
ADHD.
A review of the physician's orders revealed Client
#7 had emergency safety interventions on
03/06/2024 at 1445 [2:45 PM], 03/06/2024 at
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 16 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 144 Continued From page 16 N 144
1802 [6:02 PM], 04/13/2024 at 1011 [10:11 AM],
04/19/2024 at 0815 [8:15 AM], 08/16/2024 at
1615 [4:15 PM] and 08/17/2024 at 2016 [8:16
PM]. When the emergency safety intervention
justification packet(s) were requested from the
Director of Risk Management, the director
confirmed they were not available for the clients
records. No Emergency Safety Intervention
Justification packet(s) were completed for these
dates to document the duration of the restraint or
seclusion.
A facility policy received on 08/26/2024 titled
"Restraint or Seclusion use," revised date of
"01/2024," was reviewed and read in part that a
restraint is any manual method, physical or
mechanical device, or a drug used as a restriction
to manage a clients behavior. Seclusion is
involuntary confinement alone in a room or area
and the client is prevented from leaving. The
order for the restraint or seclusion must be time
limited to include a start and end time.
On 8/29/2024 at 11:42 AM during an interview
with the Director of Risk Management, when the
emergency safety intervention justification
packet(s) were requested, the Director of Risk
Management confirmed they were not available
for the clients records.
Review of progress notes revealed Client #1 had
diagnoses including borderline intellectual
function, disruptive mood dysregulation disorder,
and history of abuse.
Review of the facility's restraint and seclusion log
and Client #1's chart on the nurse's note dated
6/12/24, revealed Client #1 was placed in a
physical restraint from 7:47 PM to 8:08 PM. No
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 17 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 144 Continued From page 17 N 144
Emergency Safety Intervention Justification
packet was completed for these dates to
document the duration of the restraint or
seclusion. Documents were requested from the
Director of Risk Management (DRM). At 3:36 PM,
the DRM reported she was unable to locate the
ESI or physician orders regarding the incident.
Review of progress notes revealed Client #6 had
a diagnosis of disruptive mood dysregulation
disorder.
Review of the facility's "Seclusion/Restraint Log
revealed Client #6 had the following
restraint/seclusion events:
06/11/24 Physical and Chemical restraint at 8:20
PM
06/16/24 Physical restraint at 2:55 PM to 3:37 PM
and Chemical restraint at 3:11 PM
Chart revealed a nurse's note dated 04/17/24
which indicated Client #6 was placed in seclusion
at 9:26 AM and on 04/17/24 at 9:47 AM a
physician's order for seclusion was received. No
Emergency Safety Intervention Justification
packet was completed for these dates to
document the duration of the restraint or
seclusion.
N 145 ORDERS FOR USE OF RESTRAINT OR N 145
SECLUSION
CFR(s): 483.358(f)
Within 1 hour of the initiation of the emergency
safety intervention a physician, or other licensed
practitioner trained in the use of emergency
safety interventions and permitted by the state
and the facility to assess the physical and
psychological wellbeing of residents, must
conduct a face-to-face assessment of the
physical and psychological wellbeing of the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 18 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 145 Continued From page 18 N 145
resident, including but not limited to-
(1) The resident's physical and psychological
status;
(2) The resident's behavior;
(3) The appropriateness of the intervention
measures; and
(4) Any complications resulting from the
intervention.
This ELEMENT is not met as evidenced by:
Based on interview and record review, the facility
failed to ensure that an emergency safety
intervention justification packet was completed to
ensure that the face-to-face assessment was
documented for 5 (clients #1, #4, #5, #6 and #7)
case mix clients who had emergency safety
interventions.
The findings are:
Client #4 a review of the psychiatric progress note
dated 7/24/2024 revealed the client had
diagnoses of major depressive disorder
recurrent, severe, bulimia nervosa, and
post-traumatic stress disorder [PTSD].
A review of the physician's orders revealed the
Client #4 had emergency safety interventions on
06/10/2024 at 1043 [10:43 AM], 06/11/2024 at
1715 [5:15 PM] and 06/12/2024 at 1015 [10:15
AM]. No Emergency Safety Intervention
Justification packet was completed for these
dates to document the face-to-face assessment
that was to be completed within one hour of the
restraint or seclusion.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 19 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 145 Continued From page 19 N 145
A review of the psychiatric discharge summary
dated 04/24/2024 revealed Client #5 had
diagnoses of attention deficit hyperactivity
disorder [ADHD], combined presentation, conduct
disorder, oppositional defiant disorder, and manic
episode.
A review of the physician's orders revealed Client
#5 had emergency safety interventions on
03/06/2024 at 1530 [3:30 PM], 04/05/2024 at
2122 [9:22 PM], 04/17/2024 at 1336 [1:36 PM].
No Emergency Safety Intervention Justification
packet was completed for these dates to
document the face-to-face assessment that was
to be completed within one hour of the restraint or
seclusion.
A review of the Psychiatric Progress note dated
07/24/2024 revealed Client #7 had diagnoses of
disruptive mood dysregulation disorder and
ADHD.
A review of the physician's orders revealed Client
#7 had emergency safety interventions on
03/06/2024 at 1445 [2:45 PM], 03/06/2024 at
1802 [6:02 PM], 04/13/2024 at 1011 [10:11 AM],
04/19/2024 at 0815 [8:15 AM], 08/16/2024 at
1615 [4:15 PM] and 08/17/2024 at 2016 [8:16
PM]. No Emergency Safety Intervention
Justification packet was completed for these
dates to document the face-to-face assessment
that was to be completed within one hour of the
restraint or seclusion.
A facility policy received on 08/26/2024 titled
"Restraint or Seclusion Use," revision date of
"01/2024," was reviewed and read in part that a
restraint is any manual method, physical or
mechanical device, or a drug used as a restriction
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 20 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 145 Continued From page 20 N 145
to manage a clients behavior. Seclusion is
involuntary confinement alone in a room or area
and the client is prevented from leaving. The post
emergency safety intervention justification packet
and the face to face assessment should have
been completed within one hour of initiation of the
intervention.
On 8/29/2024 at 11:42 AM during an interview
with the Director of Risk Management, when
documents were requested, the Director of Risk
Management was unable to provide
documentation.
Client #1 had diagnoses including borderline
intellectual function, disruptive mood
dysregulation disorder, and history of abuse.
Review of the facility's restraint and seclusion log
and Client#1's chart on the nurse's note dated
6/12/24, revealed Client #1 was placed in a
physical restraint from 7:47 PM to 8:08 PM. No
Emergency Safety Intervention Justification (ESI)
packet was completed for 6/12/24 to document
the face-to-face assessment that was to be
completed within one hour of the restraint or
seclusion. Documents were requested from the
Director of Risk Management (DRM). At 3:36 PM,
the DRM reported she was unable to locate the
ESI or physician orders regarding the incident.
Client #6 had diagnosis of disruptive mood
dysregulation disorder.
Review of the facility's restraint and seclusion log
revealed Client #6 had the following
restraint/seclusion events:
06/11/24 Physical and Chemical restraint at 8:20
PM.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 21 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 145 Continued From page 21 N 145
06/16/24 Physical restraint at 2:55 PM to 3:37 PM
and Chemical restraint at 3:11 PM.
Chart revealed a nurse's note dated 04/17/24
which indicated Client #6 was placed in seclusion
at 9:26 AM and on 04/17/24 a physician's order
for seclusion was received. No Emergency
Safety Intervention Justification packets were
completed for these dates to document the
face-to-face assessments that were to be
completed within one hour of the restraint or
seclusion.
N 148 ORDERS FOR USE OF RESTRAINT OR N 148
SECLUSION
CFR(s): 483.358(g)(3)
[Each order for restraint or seclusion must
include] the emergency safety intervention
ordered, including the length of time for which the
physician or other licensed practitioner permitted
by the state and the facility to order restraint or
seclusion authorized its use.
This ELEMENT is not met as evidenced by:
Based on interview and record review, the facility
failed to ensure that an emergency safety
intervention justification packet was completed to
ensure that the appropriate type of intervention
was ordered and documented for 5 (clients #1,
#4, #5, #6 and #7) case mix clients who had
emergency safety interventions.
The findings are:
A review of the psychiatric progress note dated
7/24/2024 revealed Client #4 had diagnoses of
major depressive disorder recurrent, severe,
bulimia nervosa, and post-traumatic stress
disorder [PTSD].
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 22 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 148 Continued From page 22 N 148
A review of the physician's orders revealed Client
#4 had emergency safety interventions on
06/10/2024 at 1043 [10:43 AM], 06/11/2024 at
1715 [5:15 PM] and 06/12/2024 at 1015 [10:15
AM]. According to the Director of Risk
Management no Emergency Safety Intervention
Justification packet(s) was/were available to
ensure that the appropriate type of intervention
was ordered and documented for these dates.
A review of the psychiatric discharge summary
dated 04/24/2024 revealed Client #5 had
diagnoses of attention deficit hyperactivity
disorder [ADHD], combined presentation, conduct
disorder, oppositional defiant disorder, and manic
episode.
A review of the physician's orders revealed Client
#5 had emergency safety interventions on
03/06/2024 at 1530 [3:30 PM], 04/05/2024 at
2122 [9:22 PM], 04/17/2024 at 1336 [1:36 PM].
According to an interview with the Director of Risk
Management no Emergency Safety Intervention
Justification packet(s) was/were available to
ensure that the appropriate type of intervention
was ordered and documented for these dates.
A review of the Psychiatric Progress note dated
07/24/2024 revealed Client #7 had a diagnoses of
disruptive mood dysregulation disorder and
ADHD.
A review of the physician's orders revealed Client
#7 had emergency safety interventions on
03/06/2024 at 1445 [2:45 PM], 03/06/2024 at
1802 [6:02 PM], 04/13/2024 at 1011 [10:11 AM],
04/19/2024 at 0815 [8:15 AM], 08/16/2024 at
1615 [4:15 PM] and 08/17/2024 at 2016 [8:16
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 23 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 148 Continued From page 23 N 148
PM]. According to an interview with the Director of
Risk Management no Emergency Safety
Intervention Justification packet(s) was/were
available to ensure that the appropriate type of
intervention was ordered and documented for
these dates.
A facility policy received on 08/26/2024 titled,
"Restraint or Seclusion use," revised date of
"01/2024," was reviewed and read in part that a
restraint is any manual method, physical or
mechanical device, or a drug used as a restriction
to manage a clients behavior. Seclusion is
involuntary confinement alone in a room or area
and the client is prevented from leaving. The
physician's order must designate the type of
restraint/seclusion to be used.
On 8/29/2024 at 11:42 AM, during an interview
with the Director of Risk Management, when the
Emergency Safety Intervention Justification
packet(s) were requested, the director informed
this surveyor there were no justification packets
available to ensure the appropriate intervention
was ordered and documented in the clients
record.
Client #1 had diagnoses including borderline
intellectual function, disruptive mood
dysregulation disorder, and history of abuse.
Review of the facility's restraint and seclusion log
and Client #1's chart on the nurse's note dated
6/12/24 revealed Client #1 was placed in a
physical restraint from 7:47 PM to 8:08 PM. No
Emergency Safety Intervention Justification (ESI)
packet was completed for 6/12/24 to document
the type of restraint ordered. Documents were
requested from the Director of Risk Management
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 24 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 148 Continued From page 24 N 148
(DRM). At 3:36 PM, the DRM reported she was
unable to locate the ESI or physician orders
regarding the incident.
Client #6 had a diagnosis of disruptive mood
dysregulation disorder.
Review of the facility's restraint and seclusion log
revealed Client #6 had the following
restraint/seclusion events:
06/11/24 Physical and Chemical restraint at 8:20
PM.
06/16/24 Physical restraint at 2:55 PM to 3:37 PM
and Chemical restraint at 3:11 PM.
Chart revealed a nurse's note dated 04/17/24
which indicated Client #6 was placed in seclusion
at 9:26 AM and on 04/17/24 a physician's order
for seclusion was received. No Emergency
Safety Intervention Justification packets were
completed for these dates to document the type
of restraint ordered.
N 149 ORDERS FOR USE OF RESTRAINT OR N 149
SECLUSION
CFR(s): 483.358(h)
Staff must document the intervention in the
resident's record. That documentation must be
completed by the end of the shift in which the
intervention occurs. If the intervention does not
end during the shift in which it began,
documentation must be completed during the
shift in which it ends. Documentation must
include all of the following:
This ELEMENT is not met as evidenced by:
Based on interview and record review, the facility
failed to log emergency safety interventions for 5
(Clients #1, #4, #5, #6, and #7) who had
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 25 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 149 Continued From page 25 N 149
emergency safety interventions documented in
their record.
The findings are:
A review of the psychiatric progress note dated
7/24/2024 revealed Client #4 had diagnoses of
major depressive disorder recurrent, severe,
bulimia nervosa, and post-traumatic stress
disorder [PTSD].
A review of the clients record revealed Client #4
had documented emergency safety interventions
dated 06/11/2024 at 1000 [10:00 AM] and
06/12/2024 at 1140 [11:40 AM] that were not
identified on the seclusion/restraint log for the
appropriate dates.
A review of the psychiatric discharge summary
dated 04/24/2024 revealed Client #5 had
diagnoses of attention deficit hyperactivity
disorder [ADHD], combined presentation, conduct
disorder, oppositional defiant disorder, and manic
episode.
A review of the clients record revealed Client #5
had documented emergency safety interventions
dated 03/06/2024 at 1550 [3:50 PM] and
03/17/2024 at 1345 [1:45 PM], and 04/5/2024 at
2122 [9:22 PM] that were not identified on the
seclusion/restraint log for the appropriate dates.
A review of the Psychiatric Progress note dated
07/24/2024 revealed Client #7 had diagnoses of
disruptive mood dysregulation disorder and
ADHD
A review of the clients record revealed Client #7
had documented emergency safety interventions
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 26 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 149 Continued From page 26 N 149
dated 03/06/2024 at 1445 [2:45 PM and
03/06/2024 at 1802 [6:02 PM] that were not
identified on the seclusion/restraint log for the
appropriate dates.
A facility policy received on 08/26/2024 titled
"Restraint or Seclusion use" with a revised date of
01/2024 was reviewed and did not address the
requirement for logging each emergency safety
intervention [ESI].
During a conversation with the Director of Risk
Management on 08/26/2024, the surveyors were
informed that the responsibility for logging ESI's
had been given to Risk Management in April of
2024. Logging of the ESI's prior to that time had
not been consistent.
Client #1 had diagnoses including borderline
intellectual function, disruptive mood
dysregulation disorder, and history of abuse.
Review of the facility's restraint and seclusion log
and Client#1's chart on the nurse's note dated
6/12/24, revealed Client #1 was placed in a
physical restraint from 7:47 PM to 8:08 PM. No
other documents regarding the restraint were in
the client's record, specifically, no physician order
or Emergency Safety Intervention Justification
Packet (ESI) documents were requested from the
Director of Risk Management (DRM). At 3:36 PM,
the DRM reported she was unable to locate the
ESI or physician orders regarding the incident.
Client #6 had a diagnosis of disruptive mood
dysregulation disorder.
Review of the facility's restraint and seclusion log
revealed Client #6 had the following
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 27 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 149 Continued From page 27 N 149
restraint/seclusion events:
06/11/24 Physical and Chemical restraint at 8:20
PM
06/16/24 Physical restraint at 2:55 PM to 3:37 PM
and Chemical restraint at 3:11 PM
No other documents regarding the restraints were
in the client's record, specifically, no physician
order or ESI.
Chart revealed a nurse's note dated 04/17/24
which indicated Client #6 was placed in seclusion
at 9:26 AM and on 04/17/24 a physician's order
for seclusion was received. No other documents
regarding the restraints were in the client's
record.
N 151 ORDERS FOR USE OF RESTRAINT OR N 151
SECLUSION
CFR(s): 483.358(h)(2)
[Documentation must include] the time the
emergency safety intervention actually began and
ended.
This ELEMENT is not met as evidenced by:
Based on interview and record review, the facility
failed to ensure that an emergency safety
intervention justification packet was completed to
ensure that the initiation time of the
restraint/seclusion was documented for 5 (clients
#1, #4, #5, #6 and #7) case mix clients who had
emergency safety interventions
The findings are:
A review of the psychiatric progress note dated
7/24/2024 revealed Client #4 had diagnoses of
major depressive disorder recurrent, severe,
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 28 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 151 Continued From page 28 N 151
bulimia nervosa, and post-traumatic stress
disorder [PTSD].
A review of the physician's orders revealed Client
#4 had emergency safety interventions on
06/10/2024 at 1043 [10:43 AM], 06/11/2024 at
1715 [5:15 PM] and 06/12/2024 at 1015 [10:15
AM]. No Emergency Safety Intervention
Justification packet was available according to an
interview with the Director of Risk Management.
When the justification packet(s) were requested,
the director confirmed they were not available for
these dates to document the initiation time of the
restraint or seclusion.
A review of the psychiatric discharge summary
dated 04/24/2024 revealed Client #5 had
diagnoses of attention deficit hyperactivity
disorder [ADHD], combined presentation, conduct
disorder, oppositional defiant disorder, and manic
episode.
A review of the physician's orders revealed Client
#5 had emergency safety interventions on
03/06/2024 at 1530 [3:30 PM], 04/05/2024 at
2122 [9:22 PM], 04/17/2024 at 1336 [1:36 PM].
No Emergency Safety Intervention Justification
packet was available according to an interview
with the Director of Risk Management. When the
justification packet(s) were requested, the
director confirmed they were not available for
these dates to document the initiation time of the
restraint or seclusion.
A review of the Psychiatric Progress note dated
07/24/2024 revealed Client #7 had a diagnoses of
disruptive mood dysregulation disorder and
ADHD.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 29 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 151 Continued From page 29 N 151
A review of the physician's orders revealed Client
#7 had emergency safety interventions on
03/06/2024 at 1445 [2:45 PM], 03/06/2024 at
1802 [6:02 PM], 04/13/2024 at 1011 [10:11 AM],
04/19/2024 at 0815 [8:15 AM], 08/16/2024 at
1615 [4:15 PM] and 08/17/2024 at 2016 [8:16
PM]. No Emergency Safety Intervention
Justification packet was available according to an
interview with the Director of Risk Management.
When the justification packet(s) were requested,
the director confirmed they were not available for
these dates to document the initiation time of the
restraint or seclusion.
A facility policy received on 08/26/2024 titled
"Restraint or Seclusion Use," revised date of
"01/2024," was reviewed and read in part that a
restraint is any manual method, physical or
mechanical device, or a drug used as a restriction
to manage a clients behavior. Seclusion is
involuntary confinement alone in a room or area
and the client is prevented from leaving. The
physician's order must designate the start and
end times of the restraint/seclusion to be used.
On 8/29/2024 at 11:42 AM during an interview
with the Director of Risk Management, when the
Emergency Safety Intervention Justification
packet(s) were requested, the director informed
this surveyor there were no justification packets
available for these dates to document the
initiation time of the restraint or seclusion.
Review of a psychiatric progress note dated
"06/22/24" revealed Client #1 had diagnoses
including borderline intellectual function,
disruptive mood dysregulation disorder, and
history of abuse.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 30 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 151 Continued From page 30 N 151
Review of the facility's restraint and seclusion log
and Client#1's chart on the nurse's note dated
6/12/24, revealed Client #1 was placed in a
physical restraint from 7:47 PM to 8:08 PM. No
Emergency Safety Intervention Justification
packet was completed for these dates to
document the initiation time of the restraint or
seclusion. Documents were requested from the
Director of Risk Management (DRM). At 3:36 PM,
the DRM reported she was unable to locate the
ESI or physician orders regarding the incident.
Client #6 had a diagnosis of disruptive mood
dysregulation disorder.
Review of the facility's restraint and seclusion log
revealed Client #6 had the following
restraint/seclusion events:
06/11/24 Physical and Chemical restraint at 8:20
PM
06/16/24 Physical restraint at 2:55 PM to 3:37 PM
and Chemical restraint at 3:11 PM
Chart revealed a nurse's note dated 04/17/24
which indicated Client #6 was placed in seclusion
at 9:26 AM and on 04/17/24 a physician's order
for seclusion was received.
No Emergency Safety Intervention Justification
packet was completed for these dates to
document the initiation time of the restraint or
seclusion
N 152 ORDERS FOR USE OF RESTRAINT OR N 152
SECLUSION
CFR(s): 483.358(h)(3)
[Documentation must include] the time and
results of the 1-hour assessment required in
paragraph (f) of this section.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 31 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 152 Continued From page 31 N 152
This ELEMENT is not met as evidenced by:
Based on interview and record review, the facility
failed to ensure that an emergency safety
intervention justification packet was completed to
ensure that the face-to-face assessment was
documented in the clients record for 5 (clients #1,
#4, #5, #6 and #7) case mix clients who had
emergency safety interventions.
The findings are:
A review of the psychiatric progress note dated
7/24/2024 revealed Client #4 had diagnoses of
major depressive disorder recurrent, severe,
bulimia nervosa, and post-traumatic stress
disorder [PTSD].
A review of the physician's orders revealed Client
#4 had emergency safety interventions on
06/10/2024 at 1043 [10:43 AM], 06/11/2024 at
1715 [5:15 PM] and 06/12/2024 at 1015 [10:15
AM]. No Emergency Safety Intervention
Justification packet was available according to an
interview with the Director of Risk Management.
When the justification packet(s) were requested,
the director confirmed they were not available for
these dates to document the face-to-face
assessment in the clients record.
A review of the psychiatric discharge summary
dated 04/24/2024 revealed Client #5 had
diagnoses of attention deficit hyperactivity
disorder [ADHD], combined presentation, conduct
disorder, oppositional defiant disorder, and manic
episode.
A review of the physician's orders revealed Client
#5 had emergency safety interventions on
03/06/2024 at 1530 [3:30 PM], 04/05/2024 at
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 32 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 152 Continued From page 32 N 152
2122 [9:22 PM], 04/17/2024 at 1336 [1:36 PM].
No Emergency Safety Intervention Justification
packet was available according to an interview
with the Director of Risk Management. When the
justification packet(s) were requested, the
director confirmed they were not available for
these dates to document the face-to-face
assessment in the client's record.
A review of the Psychiatric Progress note dated
07/24/2024 revealed Client #7 had a diagnoses of
disruptive mood dysregulation disorder and
ADHD.
A review of the physician's orders revealed Client
#7 had emergency safety interventions on
03/06/2024 at 1445 [2:45 PM], 03/06/2024 at
1802 [6:02 PM], 04/13/2024 at 1011 [10:11 AM],
04/19/2024 at 0815 [8:15 AM], 08/16/2024 at
1615 [4:15 PM] and 08/17/2024 at 2016 [8:16
PM]. No Emergency Safety Intervention
Justification packet was available according to an
interview with the Director of Risk Management.
When the justification packet(s) were requested,
the director confirmed they were not available for
these dates to document the face-to-face
assessment in the clients record.
A facility policy received on 08/26/2024 titled
"Restraint or Seclusion use," revised date of
"01/2024," was reviewed and read in part that a
restraint is any manual method, physical or
mechanical device, or a drug used as a restriction
to manage a clients behavior. Seclusion is
involuntary confinement alone in a room or area
and the client is prevented from leaving. The
documentation requirements included that the
trained nurse should conduct a one-hour face to
face assessment.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 33 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 152 Continued From page 33 N 152
On 8/29/2024 at 11:42 AM, during an interview
with the Director of Risk Management, when the
Emergency Safety Intervention Justification
packet(s) were requested, the director confirmed
they were not available for these dates to
document the face-to-face assessment in the
clients record.
Review of a psychiatric progress note dated
"06/22/24", revealed Client #1 had diagnoses
including borderline intellectual function,
disruptive mood dysregulation disorder, and
history of abuse.
Review of the facility's restraint and seclusion log
and Client#1's chart on the nurse's note dated
6/12/24, revealed Client #1 was placed in a
physical restraint from 7:47 PM to 8:08 PM. No
Emergency Safety Intervention Justification
packet was completed for these dates to
document the face-to-face assessment in the
clients record. Documents were requested from
the Director of Risk Management (DRM). At 3:36
PM, the DRM reported she was unable to locate
the ESI or physician orders regarding the
incident.
Client #6 had a diagnosis of disruptive mood
dysregulation disorder.
Review of the facility's restraint and seclusion log
revealed Client #6 had the following
restraint/seclusion events:
06/11/24 Physical and Chemical restraint at 8:20
PM
06/16/24 Physical restraint at 2:55 PM to 3:37 PM
and Chemical restraint at 3:11 PM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 34 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 152 Continued From page 34 N 152
Chart revealed a nurse's note dated 04/17/24
which indicated Client #6 was placed in seclusion
at 9:26 AM and on 04/17/24 a physician's order
for seclusion was received.
No Emergency Safety Intervention Justification
packet was completed for these dates to
document the face-to-face assessment in the
clients record.
N 153 ORDERS FOR USE OF RESTRAINT OR N 153
SECLUSION
CFR(s): 483.358(h)(4)
[Documentation must include] the emergency
safety situation that required the resident to be
restrained or put in seclusion.
This ELEMENT is not met as evidenced by:
Based on interview and record review, the facility
failed to ensure that an emergency safety
intervention justification packet was completed to
ensure that the situation that led to restraint or
seclusion was documented in the clients record
for 5 (clients #1, #4, #5, #6, and #7) case mix
clients who had emergency safety interventions.
The findings are:
A review of the psychiatric progress note dated
7/24/2024 revealed Client #4 had diagnoses of
major depressive disorder recurrent, severe,
bulimia nervosa, and post-traumatic stress
disorder [PTSD].
A review of the physician's orders revealed Client
#4 had emergency safety interventions on
06/10/2024 at 1043 [10:43 AM], 06/11/2024 at
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 35 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 153 Continued From page 35 N 153
1715 [5:15 PM] and 06/12/2024 at 1015 [10:15
AM]. No Emergency Safety Intervention
Justification packet was available according to
the Director of Risk Management for these dates
to document the event that precipitated the
restraint or seclusion.
A review of the psychiatric discharge summary
dated 04/24/2024 revealed Client #5 had
diagnoses of attention deficit hyperactivity
disorder [ADHD], combined presentation, conduct
disorder, oppositional defiant disorder, and manic
episode.
A review of the physician's orders revealed Client
#5 had emergency safety interventions on
03/06/2024 at 1530 [3:30 PM], 04/05/2024 at
2122 [9:22 PM], 04/17/2024 at 1336 [1:36 PM].
No Emergency Safety Intervention Justification
packet was available according to the Director of
Risk Management for these dates to document
the event that precipitated the restraint or
seclusion.
A review of the Psychiatric Progress note dated
07/24/2024 revealed Client #7 had a diagnoses of
disruptive mood dysregulation disorder and
ADHD.
A review of the physician's orders revealed Client
#7 had emergency safety interventions on
03/06/2024 at 1445 [2:45 PM], 03/06/2024 at
1802 [6:02 PM], 04/13/2024 at 1011 [10:11 AM],
04/19/2024 at 0815 [8:15 AM], 08/16/2024 at
1615 [4:15 PM] and 08/17/2024 at 2016 [8:16
PM]. No Emergency Safety Intervention
Justification packet was available according to
the Director of Risk Management for these dates
to document the event that precipitated the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 36 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 153 Continued From page 36 N 153
restraint or seclusion.
A facility policy received on 08/26/2024 titled
"Restraint or Seclusion Use," revised date of
"01/2024," was reviewed and read in part that a
restraint is any manual method, physical or
mechanical device, or a drug used as a restriction
to manage a clients behavior. Seclusion is
involuntary confinement alone in a room or area
and the client is prevented from leaving.
Documentation should have included the clinical
justification for use of a restraint or seclusion.
On 8/29/2024 at 11:42 AM, during an interview
with the Director of Risk Management, when
asked to provide the emergency safety
intervention justification packets, the Director
revealed the documentation was not available.
Review of a psychiatric progress note dated
"06/22/24", revealed Client #1 had diagnoses
including borderline intellectual function,
disruptive mood dysregulation disorder, and
history of abuse.
Review of the facility's restraint and seclusion log
and Client #1's chart on the nurse's note dated
6/12/24, revealed Client #1 was placed in a
physical restraint from 7:47 PM to 8:08 PM. No
Emergency Safety Intervention Justification
packet was completed for these dates to
document the event that precipitated the restraint
or seclusion. Documents were requested from
the Director of Risk Management (DRM). At 3:36
PM, the DRM reported she was unable to locate
the ESI or physician orders regarding the
incident.
Review of a history and physical dated
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 37 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 153 Continued From page 37 N 153
"03/-7/2023" revealed Client #6 had a diagnosis
of disruptive mood dysregulation disorder.
Review of the facility's restraint and seclusion log
revealed Client #6 had the following
restraint/seclusion events:
06/11/24 Physical and Chemical restraint at 8:20
PM
06/16/24 Physical restraint at 2:55 PM to 3:37 PM
and Chemical restraint at 3:11 PM
Chart revealed a nurse's note dated 04/17/24
which indicated Client #6 was placed in seclusion
at 9:26 AM and on 04/17/24 a physician's order
for seclusion was received.
No Emergency Safety Intervention Justification
packet was completed for these dates to
document the event that precipitated the restraint
or seclusion.
N 154 ORDERS FOR USE OF RESTRAINT OR N 154
SECLUSION
CFR(s): 483.358(h)(5)
[Documentation must include] the name of staff
involved in the emergency safety intervention.
This ELEMENT is not met as evidenced by:
Based on interview and record review, the facility
failed to ensure that an emergency safety
intervention justification packet was completed to
ensure that documentation was completed for
listing the staff involved with the restraint or
seclusion in the clients record for 5 (clients #1,
#4, #5, #6 and #7) case mix clients who had
emergency safety interventions.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 38 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 154 Continued From page 38 N 154
The findings are:
A review of the psychiatric progress note dated
7/24/2024 revealed Client #4 had diagnoses of
major depressive disorder recurrent, severe,
bulimia nervosa, and post-traumatic stress
disorder [PTSD].
Review of a psychiatric progress note dated
07/24/2024 revealed Client #4 had emergency
safety interventions on 06/10/2024 at 1043 [10:43
AM], 06/11/2024 at 1715 [5:15 PM] and
06/12/2024 at 1015 [10:15 AM]. No Emergency
Safety Intervention Justification packet was
completed for these dates to document the staff
involved with the restraint or seclusion.
A review of the psychiatric discharge summary
dated 04/24/2024 revealed Client #5 had
diagnoses of attention deficit hyperactivity
disorder [ADHD], combined presentation, conduct
disorder, oppositional defiant disorder, and manic
episode.
Client #5 had emergency safety interventions on
03/06/2024 at 1530 [3:30 PM], 04/05/2024 at
2122 [9:22 PM], 04/17/2024 at 1336 [1:36 PM].
No Emergency Safety Intervention Justification
packet was completed for these dates to
document the staff involved with the restraint or
seclusion. When the Emergency safety
intervention documentation was requested, the
Director of Risk Management confirmed there
was no documentation to provide.
A review of the Psychiatric Progress note dated
07/24/2024 revealed Client #7 had diagnoses of
disruptive mood dysregulation disorder and
ADHD.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 39 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 154 Continued From page 39 N 154
Clients #7 physician's orders were reviewed and
they revealed there were no emergency safety
intervention documentation for the following
dates. Client #7 had emergency safety
interventions on 03/06/2024 at 1445 [2:45 PM],
03/06/2024 at 1802 [6:02 PM], 04/13/2024 at
1011 [10:11 AM], 04/19/2024 at 0815 [8:15 AM],
08/16/2024 at 1615 [4:15 PM] and 08/17/2024 at
2016 [8:16 PM]. No Emergency Safety
Intervention Justification packet was completed
for these dates to document the staff involved
with the restraint or seclusion. When the
Emergency safety intervention documentation
was requested, the Director of Risk Management
confirmed there was no documentation to
provide.
A facility policy received on 08/26/2024 titled
"Restraint or Seclusion Use," revised date of
"01/2024," was reviewed and read in part that a
restraint is any manual method, physical or
mechanical device, or a drug used as a restriction
to manage a clients behavior. Seclusion is
involuntary confinement alone in a room or area
and the client is prevented from leaving.
Documentation should have included the clinical
justification for use of a restraint or seclusion. The
completion of the episode review should include
the staff involved in the restraint or seclusion.
(mid page 7)
On 8/29/2024 at 11:42 AM, during an interview
with the Director of Risk Management, when the
Emergency Safety Intervention Justification
packet(s) were requested, the Director of Risk
Management was unable to locate the
documentation in or out of the clients record.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 40 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 154 Continued From page 40 N 154
Review of a psychiatric progress note dated
"06/22/24", revealed Client #1 had diagnoses
including borderline intellectual function,
disruptive mood dysregulation disorder, and
history of abuse.
- Review of the facility's restraint and seclusion
log and Client#1's chart on the nurse's note dated
6/12/24, revealed Client #1 was placed in a
physical restraint from 7:47 PM to 8:08 PM. No
Emergency Safety Intervention Justification
packet was completed for these dates to
document the staff involved with the restraint or
seclusion. Documents were requested from the
Director of Risk Management (DRM). At 3:36 PM,
the DRM reported she was unable to locate the
ESI regarding the incident.
Review of a history and physical dated
"03/-7/2023" revealed Client #6 had a diagnosis
of disruptive mood dysregulation disorder.
Review of the facility's restraint and seclusion log
revealed Client #6 had the following
restraint/seclusion events:
06/11/24 Physical and Chemical restraint at 8:20
PM
06/16/24 Physical restraint at 2:55 PM to 3:37 PM
and Chemical restraint at 3:11 PM
Chart revealed a nurse's note dated 04/17/24
which indicated Client #6 was placed in seclusion
at 9:26 AM and on 04/17/24 a physician's order
for seclusion was received.
No Emergency Safety Intervention Justification
packet was completed for these dates to
document the staff involved with the restraint or
seclusion.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 41 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 156 ORDERS FOR USE OF RESTRAINT OR N 156
SECLUSION
CFR(s): 483.358(j)
The physician or other licensed practitioner
permitted by the state and the facility to order
restraint or seclusion must sign the restraint or
seclusion order in the resident's record as soon
as possible.
This ELEMENT is not met as evidenced by:
Based on interview and record review the facility
failed to ensure that physician's orders for
restraints and seclusion were signed and in the
clients record for 4 (Clients #2, #3, #4 and #7)
case mix clients who had documented use of
restraints or seclusion.
The findings are:
A review of the Psychiatric Progress not dated
8/14/2024 revealed Client #3 had diagnoses of
disruptive mood dysregulation disorder and
conduct disorder.
A review of the clients record revealed Client #3
had physician's orders dated 08/20/2024, for a
physical and chemical restraint with a time stamp
signature of 08/26/2024 at 6:50 PM, the signed
physicians orders were placed in the clients
record on 08/27/2024 after requested by the
survey team.
A review of the psychiatric progress note dated
7/24/2024 revealed Client #4 had diagnoses of
major depressive disorder, bulimia nervosa, and
post-traumatic stress disorder [PTSD].
A review of the clients record revealed Client #4
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 42 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 156 Continued From page 42 N 156
had physician's orders for a physical or chemical
restraint and/or seclusion for the following dates,
06/08/2024 two orders, 06/10/2024 two orders,
06/12/2024 and 08/11/2024 two orders with a
time stamp signature of 08/26/2024 at 6:50 PM,
the signed physicians orders were placed in the
clients record on 08/27/24 after requested by the
survey team.
A review of the Psychiatric Progress note
revealed Client #7 had diagnoses of disruptive
mood dysregulation disorder, and ADHD.
A review of the clients record revealed Client #7
had physician's orders for a physical or chemical
restraint and/or seclusion for the following dates,
03/15/2024, 04/18/2024, 05/02/2024, 05/29/2024
two orders, 06/04/2024,07/17/2024 two orders,
07/19/2024 two orders , 07/23/2024, 08/06/2024
two orders, 08/16/2024 and 08/17/2024, with a
time stamp signature of 08/26/2024 at 6:50 PM,
the signed physicians orders were placed in the
clients record on 08/27/24 after requested by the
survey team.
A policy received on 08/29/2024 that addressed
physician's orders was reviewed and read in part
verbal and telephone orders signed by the
physician within twenty-four (24) hours.
On 8/28/2024 at 9:00 AM, during an interview the
Director of Nurses [DON] and the Director of Risk
Management agreed that physician's orders were
required for restraints or seclusion, the orders
should not be obtained at the same time, and that
the physician should have signed the orders in a
timely manner.
Review of The Master Treatment Plan dated,
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 43 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 156 Continued From page 43 N 156
"7/5/2024" revealed Client # 2 had diagnoses
including post-traumatic stress disorder,
oppositional defiant disorder, attention deficit
hyperactivity disorder, bipolar II disorder, and
borderline intellectual functioning.
Record review on 08/26/2024 at 10:00 AM,
revealed physician orders were not present in
Client #2's chart for chemical and physical
restraints for 08/11/24, 08/20/24, and physical
restraint order for 8/13/24. The Surveyor
requested physician orders from the Director of
Risk Management (DRM) at 3:36 PM.
On 08/27/2024 at 9:00 AM the Chief Executive
Officer provided the following physician orders:
-Chemical restraint order on 8/11/24 at 5:22 PM
signed on 8/26/2024 at 6:50 PM
-Physical restraint order on 8/11/24 at 5:22 PM
signed on 8/26/2024 at 6:50 PM
-Physical restraint order on 8/14/24 at 9:57 AM
signed on 8/26/2024 at 6:50 PM
-Chemical restraint order on 8/20/24 at 10:53 AM
signed on 8/26/2024 at 6:50 PM
-Physical restraint order on 8/20/24 at 10:53 AM
signed on 8/26/2024 at 6:50 PM
N 178 NOTIFICATION OF PARENT(S) OR LEGAL N 178
GUARDIAN
CFR(s): 483.366
If the resident is a minor as defined in this
subpart:
483.366(a) The facility must notify the parent(s) or
legal guardian(s) of the resident who has been
restrained or placed in seclusion as soon as
possible after the initiation of each emergency
safety intervention.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 44 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 178 Continued From page 44 N 178
This STANDARD is not met as evidenced by:
Based on interview and record review, the facility
failed to ensure that guardians were notified after
the implementation of an emergency safety
intervention for 4 (clients #4, #5, #6 and #7) case
mix clients who had restraints or seclusion
documented in their record.
The findings are:
A review of the psychiatric progress note dated
7/24/2024 revealed Client #4 had diagnoses of
major depressive disorder recurrent, severe,
bulimia nervosa, and post-traumatic stress
disorder [PTSD].
A review of the physician's orders revealed Client
#4 had emergency safety interventions
implemented on 06/08/2024 and 06/11/2024 with
no documented notification of the guardian.
A review of the psychiatric discharge summary
dated 04/24/2024 revealed client had diagnoses
of attention deficit hyperactivity disorder [ADHD],
combined presentation, conduct disorder,
oppositional defiant disorder, and manic episode.
Client #5 a review of the physician's orders
revealed the client had emergency safety
interventions implemented on 03/06/2024 and
03/17/2024 and 04/05/2024 with no documented
notification of the guardian.
A review of the Psychiatric Progress note dated
07/24/2024 revealed Client #7 had diagnoses of
disruptive mood dysregulation disorder and
ADHD.
A review of the physician's orders revealed Client
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 45 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 178 Continued From page 45 N 178
#7 had emergency safety interventions
implemented on 03/06/2024 two incidents,
03/18/2024, 04/13/2024, 04/19/2024, 05/02/2024,
05/11/2024, 08/16/2024 and 08/17/2024 with no
documented notification of the guardian.
A facility policy received on 08/26/2024 titled
"Restraint or Seclusion Use," revised date of
"01/2024," was reviewed and read in part that a
restraint is any manual method, physical or
mechanical device, or a drug used as a restriction
to manage a clients behavior. Seclusion is
involuntary confinement alone in a room or area
and the client is prevented from leaving. It read
that notification of the family or significant other
when appropriate within eight (8) hours.
On 8/29/2024 at 11:42 AM, during an interview
with the Director of Risk Management,
documentation had been requested for guardian
notification. The Director of Risk Management
informed the survey team there wasn't any
documentation available for guardian notification.
Review of a psychiatric progress note dated
"06/22/24", revealed Client #1 had diagnoses
including borderline intellectual function,
disruptive mood dysregulation disorder, and
history of abuse.
Review of the facility's restraint and seclusion log
and Client#1's chart on the nurse's note dated
6/12/24, revealed Client #1 was placed in a
physical restraint from 7:47 PM to 8:08 PM. No
Emergency Safety Intervention Justification
packet was completed for these dates to
document the notification of the guardian.
Documents were requested from the Director of
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 46 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 178 Continued From page 46 N 178
Risk Management (DRM). At 3:36 PM, the DRM
reported she was unable to locate the ESI
regarding the incident.
Review of a history and physical dated
"03/-7/2023" revealed Client #6 had a diagnosis
of disruptive mood dysregulation disorder.
Review of the facility's restraint and seclusion log
revealed Client #6 had the following
restraint/seclusion events:
06/11/24 Physical and Chemical restraint at 8:20
PM
06/16/24 Physical restraint at 2:55 PM to 3:37 PM
and Chemical restraint at 3:11 PM
Chart revealed a nurse's note dated 04/17/24
which indicated Client #6 was placed in seclusion
at 9:26 AM and on 04/17/24 a physician's order
for seclusion was received.
No Emergency Safety Intervention Justification
packet was completed for these dates to
document the notification of the guardian.
N 179 NOTIFICATION OF PARENT(S) OR LEGAL N 179
GUARDIAN
CFR(s): 483.366(b)
[If the resident is a minor as defined in this
subpart] the facility must document in the
resident's record that the parent(s) or legal
guardian(s) has been notified of the emergency
safety intervention, including the date and time of
notification and the name of the staff person
providing the notification.
This ELEMENT is not met as evidenced by:
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 47 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 179 Continued From page 47 N 179
Based on interview and record review the facility
failed to ensure that documentation for guardian
notification was in the clients record after the
implementation of an emergency safety
intervention for 3 (clients #4, #5 and #7) case mix
clients who had restraints or seclusion
documented in their record.
The findings are:
A review of the psychiatric progress note dated
7/24/2024 revealed Client #4 had diagnosis of
major depressive disorder, bulimia nervosa, and
post-traumatic stress disorder [PTSD].
A review of the physician's orders revealed Client
#4 had emergency safety interventions
implemented on 06/08/2024 and 06/11/2024 with
no documentation available in the clients record
of notification of the guardian.
A review of the psychiatric discharge summary
dated 04/24/2024 revealed Client #5 had
diagnosis of attention deficit hyperactivity disorder
[ADHD], conduct disorder, oppositional defiant
disorder, and manic episode.
A review of physician's orders revealed Client #5
had emergency safety interventions implemented
on 03/06/2024 and 03/17/2024 and 04/05/2024
with no documentation available in the clients
record of notification of the guardian.
A review of the Psychiatric Progress note dated
07/24/2024 revealed Client #7 had diagnoses of
disruptive mood dysregulation disorder and
ADHD.
A review of the physician's orders revealed Client
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 48 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 179 Continued From page 48 N 179
#7 had emergency safety interventions
implemented on 03/06/2024 two incidents,
03/18/2024, 04/13/2024, 04/19/2024, 05/02/2024,
05/11/2024, 08/16/2024 and 08/17/2024 with no
documentation available in the clients record of
notification of the guardian.
A facility policy received on 08/26/2024 titled
"Restraint or Seclusion use" with a revised date of
"01/2024" was reviewed and read in part that a
restraint is any manual method, physical or
mechanical device, or a drug used as a restriction
to manage a clients behavior. Seclusion is
involuntary confinement alone in a room or area
and the client is prevented from leaving. It also
read that notification of the family or significant
other when appropriate and that the form, to be
completed within one hour of the implementation
of a safety intervention by the nurse would
include documentation.
On 8/29/2024 at 11:42 AM during an interview
with the Director of Risk Management,
documentation had been requested for guardian
notification. The Director of Risk Management
informed the survey team there wasn't any
documentation available for guardian notification.
N 188 POST INTERVENTION DEBRIEFINGS N 188
CFR(s): 483.370(a)
Within 24 hours after the use of the restraint or
seclusion, staff involved in an emergency safety
intervention and the resident must have a
face-to-face discussion. This discussion must
include all staff involved in the intervention except
when the presence of a particular staff person
may jeopardize the wellbeing of the resident.
Other staff and the resident's parent(s) or legal
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 49 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 188 Continued From page 49 N 188
guardian(s) may participate in the discussion
when it is deemed appropriate by the facility. The
facility must conduct such discussion in a
language that is understood by the resident and
by the resident's parent(s) or legal guardian(s).
The discussion must provide both the resident
and staff the opportunity to discuss the
circumstances resulting in the use of restraint or
seclusion and strategies to be used by the staff,
the resident, or others that could prevent the
future use of restraint or seclusion.
This STANDARD is not met as evidenced by:
Based on interview and record review the facility
failed to ensure that an emergency safety
intervention justification packet was completed to
ensure that the staff face to face debriefing was
documented for the restraint or seclusion and in
the clients record for 6 (Clients #1, #2, #4, #5, #6
and #7) case mix clients who had emergency
safety interventions.
The findings are:
A review of the psychiatric progress note dated
7/24/2024 revealed Client #4 had diagnoses of
major depressive disorder recurrent, severe,
bulimia nervosa, and post-traumatic stress
disorder [PTSD].
A review of the physician's orders revealed Client
#4 had emergency safety interventions on
06/10/2024 at 1043 [10:43 AM], 06/11/2024 at
1715 [5:15 PM] and 06/12/2024 at 1015 [10:15
AM]. According to the Director of Risk
Management, there were no Emergency Safety
Intervention Justification packets available for
these dates that document the staff face-to-face
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 50 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 188 Continued From page 50 N 188
debriefing for the restraint or seclusion and
available in the clients record.
A review of the psychiatric discharge summary
dated 04/24/2024 revealed Client #5 had
diagnoses of attention deficit hyperactivity
disorder [ADHD], combined presentation, conduct
disorder, oppositional defiant disorder, and manic
episode.
A review of the physician's orders revealed Client
#5 had emergency safety interventions on
03/06/2024 at 1530 [3:30 PM], 04/05/2024 at
2122 [9:22 PM], 04/17/2024 at 1336 [1:36 PM].
According to the Director of Risk Management,
there were no Emergency Safety Intervention
Justification packets available for these dates that
document the staff face-to-face debriefing for the
restraint or seclusion and available in the clients
record.
A review of the Psychiatric Progress note dated
07/24/2024 revealed Client #7 had a diagnoses of
disruptive mood dysregulation disorder and
ADHD.
A review of the physician's orders revealed Client
#7 had emergency safety interventions on
03/06/2024 at 1445 [2:45 PM], 03/06/2024 at
1802 [6:02 PM], 04/13/2024 at 1011 [10:11 AM],
04/19/2024 at 0815 [8:15 AM], 08/16/2024 at
1615 [4:15 PM] and 08/17/2024 at 2016 [8:16
PM].According to the Director of Risk
Management, there were no Emergency Safety
Intervention Justification packets available for
these dates that document the staff face-to-face
debriefing for the restraint or seclusion and
available in the clients record.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 51 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 188 Continued From page 51 N 188
A facility policy, received on 08/26/2024, titled
"Restraint or Seclusion use," revised date of
"01/2024," was reviewed and read in part that a
restraint is any manual method, physical or
mechanical device, or a drug used as a restriction
to manage a clients behavior. Seclusion is
involuntary confinement alone in a room or area
and the client is prevented from leaving.
Documentation should have included the clinical
justification for use of a restraint or seclusion. The
completion of the documentation should include
the debriefing of staff within 24 hours to address
any needs due to the traumatic episode for staff
involved in the restraint or seclusion. (bottom and
mid page 7)
On 8/29/2024 at 11:42 AM, during an interview
with the Director of Risk Management, when the
Emergency Safety Intervention Justification
packet(s) were requested, the director informed
this surveyor there were no justification packets
available to document the staff debriefing for
these dates and were not available for the clients
record.
Review of The Master Treatment Plan dated,
"7/5/2024" revealed Client # 2 had diagnoses
including post-traumatic stress disorder,
oppositional defiant disorder, attention deficit
hyperactivity disorder, bipolar II disorder, and
borderline intellectual functioning.
Review of the facility's seclusion log and client's
chart revealed on 08/20/24 at 10:50 AM, Client #2
had a behavior event that resulted in physical and
chemical restraints. The patient debriefing form,
located in the Emergency Safety Intervention
Justification Packet (ESI) indicated one attempt
to have client complete the form. The form was
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 52 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 188 Continued From page 52 N 188
not completed.
Review of a history and physical dated
"03/-7/2023" revealed Client #6 had a diagnosis
of disruptive mood dysregulation disorder.
Review of the facility's seclusion log and client's
chart revealed on 03/18/24 at 11:04 AM, Client #6
had a behavior event that resulted in a physical
restraint. The patient debriefing form, located in
the Emergency Safety Intervention Justification
Packet (ESI) indicated one attempt to have client
complete the form. The form was not completed.
N 189 POST INTERVENTION DEBRIEFINGS N 189
CFR(s): 483.370(b)
Within 24 hours after the use of restraint or
seclusion, all staff involved in the emergency
safety intervention, and appropriate supervisory
and administrative staff, must conduct a
debriefing session that includes, at a minimum, a
review and discussion of -
483.370(b)(1) The emergency safety situation
that required the intervention, including
discussion of the precipitating factors that led up
to the intervention;
This ELEMENT is not met as evidenced by:
Based on interview and record review, the facility
failed to ensure that an emergency safety
intervention justification packet was completed to
ensure that the face-to-face debriefing was
documented for the restraint or seclusion and in
the clients record for 5 (clients #1, #4, #5, #6 and
#7) case mix clients who had emergency safety
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 53 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 189 Continued From page 53 N 189
interventions.
The findings are:
A review of the psychiatric progress note dated
7/24/2024 revealed Client #4 had diagnoses of
major depressive disorder recurrent, severe,
bulimia nervosa, and post-traumatic stress
disorder [PTSD].
A review of the physician's orders revealed Client
#4 had emergency safety interventions on
06/10/2024 at 1043 [10:43 AM], 06/11/2024 at
1715 [5:15 PM] and 06/12/2024 at 1015 [10:15
AM]. According to the Director of Risk
Management, there were no Emergency Safety
Intervention Justification packets available for
these dates to document the face-to-face
debriefing for the restraint or seclusion and in the
clients record
A review of the psychiatric discharge summary
dated 04/24/2024 revealed Client #5 had
diagnoses of attention deficit hyperactivity
disorder [ADHD], combined presentation, conduct
disorder, oppositional defiant disorder, and manic
episode.
A review of the physician's orders revealed Client
#5 had emergency safety interventions on
03/06/2024 at 1530 [3:30 PM], 04/05/2024 at
2122 [9:22 PM], 04/17/2024 at 1336 [1:36 PM].
According to the Director of Risk Management,
there were no Emergency Safety Intervention
Justification packets available for these dates to
document the face-to-face debriefing for the
restraint or seclusion and in the clients record
A review of the Psychiatric Progress note dated
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 54 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 189 Continued From page 54 N 189
07/24/2024 revealed Client #7 had diagnoses of
disruptive mood dysregulation disorder and
ADHD.
A review of the physician's orders revealed Client
#7 had emergency safety interventions on
03/06/2024 at 1445 [2:45 PM], 03/06/2024 at
1802 [6:02 PM], 04/13/2024 at 1011 [10:11 AM],
04/19/2024 at 0815 [8:15 AM], 08/16/2024 at
1615 [4:15 PM] and 08/17/2024 at 2016 [8:16
PM]. According to the Director of Risk
Management, there were no Emergency Safety
Intervention Justification packets available for
these dates to document the face-to-face
debriefing for the restraint or seclusion and in the
clients record
A facility policy received on 08/26/2024 titled
"Restraint or Seclusion Use," revised date of
"01/2024," was reviewed and read in part that a
restraint is any manual method, physical or
mechanical device, or a drug used as a restriction
to manage a clients behavior. Seclusion is
involuntary confinement alone in a room or area
and the client is prevented from leaving.
Documentation should have included the clinical
justification for use of a restraint or seclusion. The
completion of the documentation should include
the debriefing of staff within 24 hours to address
any needs due to the traumatic episode for staff
involved in the restraint or seclusion.
On 8/29/2024 at 11:42 AM, during an interview
with the Director of Risk Management, when the
Emergency Safety Intervention Justification
packet(s) were requested, the director informed
this surveyor there were no justification packets
available to document the face to face debriefing
of the restraint or seclusion and available in the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 55 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 189 Continued From page 55 N 189
clients record.
N 193 POST INTERVENTION DEBRIEFINGS N 193
CFR(s): 483.370(c)
Staff must document in the resident's record that
both debriefing sessions took place and must
include in that documentation the names of staff
who were present for the debriefing, names of
staff who were excused from the debriefing, and
any changes to the resident's treatment plan that
result from the debriefings.
This ELEMENT is not met as evidenced by:
Based on interview and record review, the facility
failed to ensure that documentation for staff and
client debriefing for the restraint or seclusion had
been completed and available in the clients
record for 5 (Clients #1, #4, #5, #6, and #7) case
mix clients who had emergency safety
interventions.
The findings are:
A review of the psychiatric progress note dated
7/24/2024 revealed Client #4 had diagnoses of
major depressive disorder recurrent, severe,
bulimia nervosa, and post-traumatic stress
disorder [PTSD]..
A review of the physician's orders revealed Client
#4 had emergency safety interventions on
06/10/2024 at 1043 [10:43 AM], 06/11/2024 at
1715 [5:15 PM] and 06/12/2024 at 1015 [10:15
AM]. According to the Director of Risk
Management, no Emergency Safety Intervention
Justification packets were available for these
dates to verify documentation of the debriefing
after a safety intervention for staff or the client.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 56 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 193 Continued From page 56 N 193
A review of the psychiatric discharge summary
dated 04/24/2024 revealed Client #5 had
diagnoses of attention deficit hyperactivity
disorder [ADHD], combined presentation, conduct
disorder, oppositional defiant disorder, and manic
episode.
A review of the physician's orders revealed Client
#5 had emergency safety interventions on
03/06/2024 at 1530 [3:30 PM], 04/05/2024 at
2122 [9:22 PM], 04/17/2024 at 1336 [1:36 PM].
According to the Director of Risk Management,
no Emergency Safety Intervention Justification
packets were available for these dates to verify
documentation of the debriefing after a safety
intervention for staff or the client.
A review of the Psychiatric Progress note dated
07/24/2024 revealed Client #7 had diagnoses of
disruptive mood dysregulation disorder and
ADHD.
A review of the physician's orders revealed Client
#7 had emergency safety interventions on
03/06/2024 at 1445 [2:45 PM], 03/06/2024 at
1802 [6:02 PM], 04/13/2024 at 1011 [10:11 AM],
04/19/2024 at 0815 [8:15 AM], 08/16/2024 at
1615 [4:15 PM] and 08/17/2024 at 2016 [8:16
PM]. According to the Director of Risk
Management, no Emergency Safety Intervention
Justification packets were available for these
dates to verify documentation of the debriefing
after a safety intervention for staff or the client.
A facility policy received on 08/26/2024 titled
"Restraint or Seclusion use" with a revised date of
"01/2024" was reviewed and read in part that a
restraint is any manual method, physical or
mechanical device, or a drug used as a restriction
to manage a clients behavior. Seclusion is
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 57 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 193 Continued From page 57 N 193
involuntary confinement alone in a room or area
and the client is prevented from leaving.
Documentation should have included the clinical
justification for use of a restraint or seclusion. The
completion of the documentation should include
the debriefing of staff within 24 hours to address
any needs due to the traumatic episode for staff
involved in the restraint or seclusion. The policy
did not address the requirement for maintaining
restraint or seclusion documents available in the
clients records. (bottom and mid page 7)
On 8/29/2024 at 11:42 AM, during an interview
with the Director of Risk Management, when the
Emergency Safety Intervention Justification
packet(s) were requested, that included the
debriefing of the client and staff. The director
informed this surveyor there were no justification
packets available for these dates that
documented staff and client debriefing for the
restraint or seclusion and available in the clients
record.
Review of a psychiatric progress note dated
"06/22/24", revealed Client #1 had diagnoses
including borderline intellectual function,
disruptive mood dysregulation disorder, and
history of abuse.
Review of the facility's restraint and seclusion log
and Client#1's chart on the nurse's note dated
6/12/24, revealed Client #1 was placed in a
physical restraint from 7:47 PM to 8:08 PM. No
Emergency Safety Intervention Justification
packet was completed for these dates to
document the debriefing for the restraint or
seclusion and available in the clients record.
Documents were requested from the Director of
Risk Management (DRM). At 3:36 PM, the DRM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 58 of 59

PRINTED: 09/16/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L120 B. WING _____________________________ 08/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2466 S 48TH STREET
WOODRIDGE OF THE OZARKS
SPRINGDALE, AR 72762
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 193 Continued From page 58 N 193
reported she was unable to locate the ESI
regarding the incident.
Review of a medical history and physical dated
"03/07/2023" revealed Client #6 had a diagnosis
of disruptive mood dysregulation disorder.
Review of the facility's restraint and seclusion log
revealed Client #6 had the following
restraint/seclusion events:
06/11/24 Physical and Chemical restraint at 8:20
PM
06/16/24 Physical restraint at 2:55 PM to 3:37 PM
and Chemical restraint at 3:11 PM
Chart revealed a nurse's note dated 04/17/24
which indicated Client #6 was placed in seclusion
at 9:26 AM and on 04/17/24 a physician's order
for seclusion was received.
No Emergency Safety Intervention Justification
packet was completed for these dates to
document the debriefing for the restraint or
seclusion and available in the clients record.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:70KM11 Facility ID: 3017 If continuation sheet Page 59 of 59

Division of Provider Services
& Quality Assurance
P.O. Box 8059, Slot S404
Little Rock, AR 72203-8059
September 26, 2024
Derek Thompson, Administrator
Woodridge Of The Ozarks
2466 S 48th Street
Springdale, AR 72762
Dear Mr. Thompson:
On August 30, 2024, we conducted a Complaint Investigation survey at your facility. You have alleged
that the deficiencies cited on that survey have been corrected. We are accepting your allegation of
compliance and have approved your plan of correction and presume that you will achieve substantial
correction by September 30, 2024.
We will be conducting a revisit of your facility to verify that substantial correction has been achieved
and maintained.
If you have any questions, please contact your reviewer: Breanna Marengo at 501-320-6280 or email
to: breanna.marengo@dhs.arkansas.gov.
Sincerely,
Breanna Marengo
Breanna Marengo, Reviewer
DPSQA/Office of Long Term Care
Survey & Certification Section
bbm
Derek Thompson - Woodridge Of The Ozarks -- -- (AOLTC-14) Page 1

Perimeter Healthcare of the Ozarks POC Approved BBM
09/26/24 @ 1543
Plan of Correction
Return to OLTC by 9.25.2024 Plan of Correction Received: 9.16.2024
Completed by: Skyler Barnes POC Completion Date: 9.30.2024
Job Title: Facility CEO
Date Completed: 9.24.2024
Regulation Deficiency Completion
Action to be taken
Date by
9.30.2024
Protection of To ensure client is free from All emergency safety interventions (ESI) will Implemented
Residents chemical restraint. continue to be monitored and tracked on our 9.20.2024
CFR(s):
restraint log by of Director of Risk. With continuous
483.256 (a) (1)
monitoring for
90 days
100% of all Emergency Safety Interventions Implemented
(ESIs) will be reviewed via camera footage 9.10.24
within next business day of occurrence until
compliance with protocols for appropriate use of
restraint, seclusion, or emergency medications is
met and maintained at 100% for 30 consecutive
days.
All current MHTs/Nurses will be re-trained on 9.30.2024
appropriate use of ESI protocols.
- PRNs will be trained before their next
shift for those unable to train prior to
9.30.24.
- Staff who do not complete training prior
to 9.30.24 will not work the schedule
until training has been completed.
PROTECTION To ensure that clients who All current MHTs/Nurses will be re-trained on 9.30.2024
OF RESIDENTS underwent emergency safety appropriate use of ESI protocols.
CFR(s):
interventions did not sustain - PRNs will be trained before their next
483.356(a)(3)
potentially avoidable injuries shift for those unable to train prior to
during the process. 9.30.24.
- Staff who do not complete training prior
to 9.30.24 will not work the schedule
until training has been completed.
100% of direct care and clinical staff will Implemented
complete the initial Handle With Care (HWC) 9.30.24
certification and be re-certified every 6 months.
A tracking system has been developed and
Daily
implemented to monitor certification and re-
monitoring until
certification status, ensuring full compliance and
100%
timely completion for all staff. Compliance will
compliance and
be monitored and reviewed monthly by the
then monthly
Committee of the Whole (COW) to ensure
monitoring via
adherence to these standards.
COW meeting
ORDERS FOR Physician’s order for restraints All current charts have been audited to identify 9.18.2024
USE OF and seclusion deficiencies. All appropriate corrections will be

RESTRAINT completed.
OR
SECLUSION Nursing will be re-trained on ESI protocols to 9.30.2024
CFR(s): include proper timelines for physician orders
483.358(b)
following or prior to a restraint, seclusion, or
483.358(j)
emergency mediation.
- PRNs will be trained before their next
shift for those unable to train prior to
9.30.24.
- Nurses who do not complete training
prior to 9.30.24 will not work the
Doctor have been set up with Docusign to ensure Implemented
schedule until training has been
timely review of orders. These will be 9.25.2024
completed.
authenticated within 24 hours.
Daily
During weekends/holidays, administrator on-call monitoring until
(AOC) will take point on sending physician 100%
orders to doctor. compliance and
then monthly
Compliance will be monitored and reviewed monitoring via
regularly by the Committee of the Whole to COW meeting
ensure adherence to these standards.
The nursing team will file POs physical chart 9.10.2024
within 48 hours.
ORDERS FOR To ensure physician's orders for Nursing and Physicians will be re-trained on ESI 9.30.24
USE OF physical and chemical restraints protocols to include proper timelines for
RESTRAINT
were not received at the same initiating restraints, seclusion, or emergency
OR
time. medications and obtaining orders from the
SECLUSION
CFR(s): physician.
483.358(c) - PRNs will be trained before their next
shift for those unable to train prior to
9.30.24.
- Nurses who do not complete training
prior to 9.30.24 will not work the
schedule until training has been
completed.
- Physicians will complete re-training prior
to their next scheduled round.
All direct care and clinical staff will be HWC 9.30.2024
certified and be re-certified every 6 months, to
include de-escalation techniques that will assist
MHT/Nurses in implementing de-escalation Daily
techniques before moving to a more restrictive monitoring until
alternative. 100%
compliance and
then monthly
monitoring via
COW meeting

ORDERS FOR Failure to complete emergency All current charts have been audited to identify Implemented
USE OF safety intervention justification deficiencies. All appropriate corrections will be 9.25.2024
RESTRAINT
packet to include: completed.
OR
-duration of the safety Monthly
SECLUSION
CFR(s): intervention was documented A nursing chart audit will be occurring monthly ongoing
483.358(e) - face-to-face assessment was for ongoing compliance verification. monitoring
483.358(f) documented reviews via
483.358(h)
- the appropriate type of COW meeting
483.358(h)(2)
intervention was ordered and
483.358(h)(3)
483.358(h)(4) documented Nursing will be re-trained on ESI protocols to 9.30.2024
483.358(h)(5) - log emergency safety include the completion of the ESI packet to
483.370(a) interventions include quality, timeliness, additional
483.370(b) - initiation time of the documentation if warranted, physician order, and
483.370(c)
restraint/seclusion was filing process.
documented
Monitoring Process Steps: Implemented
- the situation that led to restraint
- Nursing completion of packet 9.10.204
or seclusion was documented
- ESI packet entered into chart with physician
- listing the staff involved with
orders within 48 hours Daily
the restraint or seclusion
- Copy of ESI packet given to Director of Risk monitoring until
- the staff face to face debriefing
- Director of Risk will review ESI for 100%
was documented
completeness, justification, and appropriate ESI compliance and
- the face-to-face debriefing was
protocols. then monthly
documented
- Director of Risk will log ESI on restraint log to monitoring via
- staff and client debriefing for
track ESIs COW meeting
the restraint or seclusion had
- Director of Risk will turn ESI packets that are
been completed and available in
not completed fully or adequately into Director
the client’s record
of Nursing for review with RN.
- Director of Risk will review cameras for all
ESIs over a 30-day period to verify accuracy of
ESI packet report.
- Compliance issues will be referred to DON for
disciplinary action.
Compliance will be monitored and reviewed
monthly by the Committee of the Whole to
ensure adherence to these standards.
NOTIFICATIO To ensure that guardians were The administrator on-call (AOC) will complete Implemented
N OF notified after the implementation check-ins with day/evening shifts to identify any 9.16.204
PARENT(S) OR
of an emergency safety ESIs that may have occurred. AOC will prompt
LEGAL
intervention nursing on guardian notifications for any Daily
GUARDIAN
CFR(s): incidents/ESIs that occurred if nursing failed to monitoring until
483.366 Documentation for guardian have done so. AOC will review on-call each 100%
483.366(b) notification was in the client’s morning and make note of any incidents/ESIs to compliance and
record be tracked on morning meeting notes. then monthly
monitoring via
COW meeting

ESI packets will be turned in to the Director of Implemented
Nursing who will note deficiencies with any 9.25.204
items missing in the documentation. The Director
of Nursing will meet with the Nurse to review
deficiencies in documentation, such as guardian
notification.

doc_type: Complaint Survey