SPRINGDALE, AR - Federal inspectors found immediate jeopardy conditions at Westwood Health and Rehab after discovering a vulnerable dementia patient suffered repeated physical altercations over nine months, culminating in a broken hip that required emergency surgery.
Pattern of Physical Altercations Goes Unaddressed
The January 31, 2025 inspection revealed that Resident #44, a patient with moderate cognitive impairment due to dementia, experienced ten documented physical altercations between April 2024 and January 2025. The incidents occurred despite the resident being housed in the facility's secure Alzheimer's unit, which is specifically designed to protect vulnerable patients.
Federal inspectors documented a troubling escalation of violence against the resident. The altercations began in April 2024 when Resident #44 was first pushed to the ground by another resident. Subsequent incidents included being kicked, struck in the face, punched in the stomach, and repeatedly pushed to the floor. The final incident on January 8, 2025, resulted in the resident being "pushed to the floor by another resident and appeared to be in severe pain," according to the inspection report.
The resident's medical records showed they required emergency hospitalization and surgery for a left femur fracture following the final altercation. Hospital records confirmed the diagnosis and documented the need for surgical intervention to repair the injury.
Inadequate Care Planning and Supervision Failures
Inspectors determined that Westwood's care planning process failed to protect the vulnerable resident despite clear warning signs. The facility's care plan acknowledged that Resident #44 had a tendency to wander into other residents' rooms and would take items belonging to others, behaviors that consistently triggered aggressive responses from other residents.
The care plan called for one-on-one supervision beginning August 21, 2024, yet staff interviews revealed this critical intervention was not consistently implemented. During the final incident, two certified nursing assistants who should have been monitoring the unit were instead at the nurses' station, watching security cameras while one trained the other on documentation procedures.
"CNA #2 stated she looked up at the camera and saw Resident #44 walk towards the other resident and CNA #2 got up and ran from the nurse's desk to get Resident #44," according to staff interviews conducted during the inspection. This account demonstrated that the required one-on-one supervision was not in place at the time of the incident.
A Licensed Practical Nurse told inspectors that "the intervention of redirecting Resident #44 was not an appropriate intervention because the resident would just continue with the behavior," and suggested that "an appropriate intervention would have been to remove one of the residents from the neighborhood."
Medical Significance of Dementia Care Failures
Patients with dementia require specialized care protocols due to their cognitive impairment and increased vulnerability. The brain changes associated with dementia affect judgment, impulse control, and the ability to understand consequences, making these patients particularly susceptible to harm in environments where aggressive behaviors occur.
Hip fractures in elderly residents represent a serious medical emergency with significant long-term consequences. Studies show that hip fractures in nursing home residents are associated with increased mortality rates, reduced mobility, and decreased quality of life. The surgical repair required for this resident's injury carries additional risks, including complications from anesthesia, infection, and prolonged recovery periods.
The repeated physical trauma documented in this case could have caused cumulative health effects beyond the visible injuries. Multiple incidents of being pushed, punched, and struck can result in soft tissue damage, bruising, and psychological trauma, even when no fractures are immediately apparent.
Delayed Medical Response to Stroke Symptoms
In a separate violation, inspectors found that facility staff failed to provide timely medical intervention when another resident showed clear signs of a stroke. Resident #112, who had a history of atrial fibrillation and was taking blood-thinning medication, displayed classic stroke symptoms including slurred speech and left-side weakness around 3:23 PM on October 3, 2024.
Despite staff recognition of these concerning symptoms, the resident was not sent to the emergency room until approximately four hours later, at 7:52 PM. Medical protocols for stroke response emphasize that "time is brain," meaning that each minute of delay in treatment can result in the loss of millions of brain cells.
The facility's physician confirmed during the eventual telemedicine consultation that the resident had "significant left sided facial droop on exam, had slurred speech" and required immediate emergency evaluation for a possible stroke. Hospital imaging later confirmed a medium vessel occlusion, a type of stroke that requires urgent intervention.
Due to the four-hour delay, the resident was no longer eligible for thrombolytic therapy, a clot-dissolving treatment that can significantly improve stroke outcomes when administered within the appropriate time window. This delay potentially affected the resident's long-term recovery and functional capacity.
Administrative Oversights and Reporting Failures
The inspection revealed significant gaps in the facility's administrative oversight and regulatory compliance. Of the ten physical altercations involving Resident #44, only one incident was reported to the State Agency as required by federal regulations.
During interviews, the facility Administrator demonstrated unfamiliarity with mandatory reporting requirements, stating incorrectly that "only interactions that resulted in injury should be reported." This misunderstanding of federal requirements meant that nine serious incidents went unreported to oversight authorities who could have intervened to protect the resident.
The facility also lacked a current Clinical Laboratory Improvement Amendment (CLIA) certificate appropriate for the level of testing performed within the facility, indicating broader compliance issues with federal healthcare standards.
Additional Issues Identified
Inspectors documented several other concerning practices during the survey. Staff training on behavioral interventions was incomplete, with only 45 of 105 facility employees having received required training on handling residents with dementia-related behaviors.
The facility's investigation of the final incident concluded that abuse could not be substantiated because both residents involved were deemed to lack mental capacity. However, federal regulations specify that cognitive impairment does not automatically preclude deliberate actions from being classified as abuse.
Monthly staff training on behavioral interventions had been disrupted, and administrators could not locate recent training documentation. This gap in ongoing education contributed to staff's apparent lack of understanding about appropriate interventions for residents with dementia.
The inspection resulted in immediate jeopardy findings, the most serious level of federal citation, indicating that the facility's practices posed an immediate threat to resident health and safety. Federal officials required an immediate removal plan and conducted follow-up verification to ensure corrective actions were implemented before removing the citation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westwood Health and Rehab, Inc from 2025-01-31 including all violations, facility responses, and corrective action plans.
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