Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Woodbriar Nursing Home during CMS and state inspections, most recent first.
Inaccurate MDS coding affected three residents. One resident was coded for an anticoagulant when the record showed only an antiplatelet, another resident’s MDS failed to reflect documented falls and the use of bed and wheelchair alarms, and a third resident was coded as having an indwelling catheter and IV meds despite records showing the Foley order had been discontinued and the IV antibiotic was time-limited. The MDS Coordinator acknowledged the coding errors.
A CNA verbally abused a resident with moderate cognitive impairment after the resident drank the CNA’s protein shake, yelling, cussing, and using derogatory language in the dining area. Multiple staff witnessed the incident, and the CNA admitted to cussing at the resident. The resident had dementia, bipolar disorder, and impaired cognition, and the facility’s interviews confirmed the event occurred.
A facility failed to document a care plan for a resident with severe cognitive impairment who was receiving anticoagulants, specifically Eliquis, despite it being administered within the last seven days of the assessment period. The care plan, updated recently, lacked any mention of these medications, and the MDS Coordinator confirmed the omission.
The facility failed to ensure five NAs completed competency training and certification testing within 120 days of their initial training. Employee records lacked documentation of competencies, and the facility misunderstood the timeframe for certification. The facility did not have a training protocol, relying instead on informal training without documented skills check-off.
The facility's Arbitration Agreement failed to include provisions for selecting a neutral arbitrator and a convenient venue for both parties. The HR/Social staff explained the arbitration process during admission, but the agreement did not specify mutual agreement on these aspects. The Administrator confirmed the omission, noting the agreement only referenced resolution under National Arbitration Forum rules.
Inaccurate MDS Coding for Medications, Falls, Alarms, and Catheter Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurate and complete for three residents. For Resident #4, the quarterly MDS with an ARD of 02/09/2026 coded the resident as receiving an anticoagulant and an antiplatelet, but the record showed the resident was taking an antiplatelet medication ordered for atherosclerotic heart disease. The admission MDS also showed the resident was not taking an anticoagulant. The care plan initiated on 12/05/2025 identified anticoagulant therapy and included interventions related to anticoagulant use, while the MDS Coordinator later stated the resident was taking an antiplatelet and that the anticoagulant coding was wrong. For Resident #17, the quarterly MDS with an ARD of 02/16/2026 indicated no falls since admission and no alarms in use, but the care plan documented actual falls on 12/23/2025, 12/31/2025, and 02/06/2026. The care plan and physician orders showed use of bed and wheelchair alarms, and MAR-TAR documentation also reflected monitoring of those alarms. During observation, the resident was seen sitting in a wheelchair with a chair alarm in place. The MDS Coordinator reviewed the chart and confirmed the quarterly MDS did not mark alarms, stating this was an MDS discrepancy. For Resident #64, the quarterly MDS with an ARD of 02/16/2026 indicated an indwelling catheter and IV medications. However, the order summary showed the Foley catheter order had been discontinued months earlier, and the IV antibiotic order had a limited start and end date in November 2025. The MDS Coordinator stated the IV medication information came from the MAR, but that IV medication had been entered in error, and that the resident did not have a Foley catheter. The ADON also stated the resident had not had a Foley catheter for several months.
Verbal Abuse Toward Resident in Dining Area
Penalty
Summary
The facility failed to protect a resident from verbal and mental abuse when a CNA yelled and cursed at the resident after the resident drank the CNA’s protein shake. The resident had been admitted with diagnoses including dementia, mood disorder, bipolar disorder, altered mental status, a sleeping disorder, and excessive persistent thirst with an insatiable urge to drink fluids. An annual MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and the care plan identified impaired cognitive function and thought process, along with the need for assistance and cues with ADLs and hydration-related care. Witness statements and staff interviews consistently described the CNA using expletives and derogatory language toward the resident in the dining area. An LPN heard the CNA screaming and cussing at the resident, including statements such as asking why the resident drank the CNA’s protein shake and telling the resident not to touch anything that was not theirs. Other staff reported hearing the CNA call the resident a derogatory name, yell at the resident, and make comments about drinking the resident’s milk in retaliation. The CNA acknowledged getting upset and cussing at the resident, stating that the resident should leave things alone that were not theirs. The facility’s own interviews confirmed the incident occurred and that the CNA was terminated for cussing at the resident. Staff stated there were lockers and closets available for employees to store personal items, and multiple witnesses reported the CNA had placed the drink on the table in the resident dining area before the resident drank from it. The report also notes the facility had resident rights and abuse prohibition materials on file, including definitions of verbal abuse and expectations for respectful treatment, yet the incident still occurred.
Failure to Document Anticoagulant Care Plan
Penalty
Summary
The facility failed to document and complete a person-centered care plan for a resident with severe cognitive impairment, who was admitted with diagnoses of cerebral infarction, hypertension, and congestive heart failure. The resident's quarterly Minimum Data Set (MDS) indicated that anticoagulants, specifically Eliquis, were administered within the last seven days of the assessment reference date. However, the resident's care plan, updated on 10/9/2024, did not include any documentation or planning for the use of anticoagulants or Eliquis. During an interview, the MDS Coordinator confirmed that there was no care planning involving these medications.
Failure to Ensure NA Competency and Certification
Penalty
Summary
The facility failed to ensure that five Nursing Assistants (NAs) completed competency training and certification testing within 120 days from the completion of their initial training. Upon review of employee records, it was found that all five NAs were hired within the last three months and had not completed the certification process. The only documentation available was the certificates indicating the completion of the initial 90-hour training, with no records of competencies from the initial training or from the facility itself. Interviews with the Human Resources/Social Services (HR/Social) confirmed the lack of documentation and the misunderstanding that NAs had one year to complete their certification testing. The Administrator confirmed the facility's misconception regarding the timeframe for certification testing and acknowledged the absence of a training protocol or policy for NA training and certification. The facility relied on assigning NAs to follow a Certified Nursing Assistant (CNA) for training without documenting a skills check-off list. The Administrator stated that while continued training and random monitoring were provided to ensure quality care, there was no documentation of initial skills training available.
Arbitration Agreement Lacks Neutral Arbitrator and Venue Provisions
Penalty
Summary
The facility failed to include provisions for the selection of a neutral arbitrator and a convenient venue for both parties in its Arbitration Agreement. On October 7, 2024, the facility's Arbitration Agreement was reviewed as part of the admission packet. During an interview on October 9, 2024, the Human Resource/Social staff explained that during admission, arbitration is defined as a process where disputes are handled by an arbitrator instead of going to court. However, the agreement does not specify that the selection of a neutral arbitrator and a convenient venue for both parties is required. On October 10, 2024, the Administrator confirmed that the agreement states disputes would be resolved under the National Arbitration Forum rules but does not explicitly mention the need for mutual agreement on a neutral arbitrator or a convenient venue.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Harrisburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Craighead Nursing Center | 9.9 mi | — | 4 | 0 |
| Quail Run Health And Rehab | 12.3 mi | — | 0 | 0 |
| The Springs Jonesboro | 16 mi | ★★★★★ | 2 | 0 |
| St Elizabeth's Place | 16.7 mi | ★★★★★ | 1 | 1 |
| Three Rivers Health And Rehabilitation Center | 16.7 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.