SPRINGDALE, AR - Federal inspectors have cited Westwood Health and Rehab for multiple serious safety violations following an investigation that revealed a pattern of resident-to-resident altercations on the facility's secure dementia unit, culminating in a resident fracturing their hip during an attack by another resident.
Pattern of Violence in Dementia Unit Goes Unaddressed
The most severe violation involved a resident with dementia who was repeatedly physically attacked by other residents over a nine-month period. The targeted resident, identified in the report as Resident #44, experienced ten documented incidents of physical aggression between April 2024 and January 2025, including being pushed, kicked, punched, and struck in the face and head.
The incidents escalated on January 8, 2025, when another resident pushed Resident #44 into a wall, causing a hip fracture that required emergency surgery. Hospital records confirmed the resident was diagnosed with a left femur fracture and underwent surgical repair.
According to the inspection report, Resident #44 had dementia with agitation and wandering behaviors, often entering other residents' rooms and taking items. The facility's care plan indicated the resident needed "a secured/special care neighborhood due to dementia" and required one-on-one observation as of August 21, 2024. However, staff interviews revealed this supervision was not consistently provided.
"CNA #2 stated she was aware of an altercation between another resident and Resident #44 and stated the other resident was eating a snack when Resident #44 entered the resident's room and tried to grab the snack. This resulted in the other resident pushing Resident #44 to the floor," the report documented.
Inadequate Care Planning Leads to Immediate Jeopardy
Inspectors determined the facility's failure to develop and implement an effective care plan for managing Resident #44's behaviors created an immediate jeopardy situation - the most serious level of violation indicating imminent risk of serious injury or death. The violation was classified as immediate jeopardy because the lack of effective interventions resulted in repeated resident-to-resident abuse that caused serious physical harm.
The facility's interventions proved inadequate for protecting the vulnerable resident. Care plan strategies included encouraging the resident to fold laundry or care for a baby doll when wandering, but these passive redirections failed to prevent the dangerous encounters. Multiple staff members acknowledged that simple redirection was insufficient for managing the resident's behaviors.
"LPN #12 stated that the intervention of redirecting Resident #44 was not an appropriate intervention because the resident would just continue with the behavior. LPN #12 stated that an appropriate intervention would have been to remove one of the residents from the neighborhood," according to the inspection findings.
Medical Analysis: Why These Violations Matter
Dementia care requires specialized approaches because residents with cognitive impairment cannot fully understand or control their behaviors. When a resident with dementia wanders into others' spaces and takes items, this behavior stems from their neurological condition, not intentional misconduct. Proper dementia care protocols require environmental modifications, structured activities, and adequate staffing ratios to prevent conflicts.
The repeated physical altercations indicate multiple care failures. Residents with dementia who exhibit wandering behaviors need constant supervision, particularly in secure units where other cognitively impaired residents may react aggressively to perceived intrusions. The facility's care plan acknowledged Resident #44 required one-on-one supervision, but this critical intervention was inconsistently implemented.
Hip fractures in elderly residents carry serious medical consequences, including increased mortality risk, permanent mobility loss, and prolonged recovery periods. For residents with dementia, the trauma and hospitalization can accelerate cognitive decline and reduce quality of life significantly.
Staff Supervision Failures During Critical Incident
The final incident that resulted in the hip fracture occurred while two nursing assistants were at the nurses' station rather than providing direct supervision on the unit. Staff members told inspectors they were monitoring residents through security cameras while one assistant trained another 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," the report stated, demonstrating the surveillance method was insufficient to prevent harmful interactions.
Professional dementia care standards require direct visual supervision, not camera monitoring, for residents at high risk for behavioral incidents. The delay between observing the situation on camera and physically intervening allowed enough time for the assault to occur and cause serious injury.
Delayed Response to Stroke Symptoms
In a separate incident, the facility failed to provide prompt medical attention to a resident showing signs of stroke. Resident #112, who had a history of atrial fibrillation and was on blood-thinning medication, developed slurred speech and other neurological symptoms around 3:23 PM on October 3, 2024. However, the resident was not evaluated by a medical provider until 7:35 PM - approximately four hours after symptoms began.
The delayed response proved critical because stroke treatment is time-sensitive. When the resident finally reached the hospital, imaging revealed a blocked blood vessel, but the resident was no longer eligible for clot-dissolving medication due to the time delay. This type of medication must be administered within a specific timeframe to be effective.
The facility's own policy required prompt notification of physicians for changes in resident condition, but documentation showed conflicting accounts of whether the resident's doctor was actually contacted during the initial hours when intervention could have been most beneficial.
Additional Issues Identified
Inspectors documented several other safety violations during the survey:
Improper Transfer Techniques: Staff improperly lifted a fallen resident by placing hands under the resident's armpits instead of using a gait belt, creating risk of shoulder injury.
Equipment Safety Failures: Nursing assistants locked the rear wheels of a mechanical lift while transferring a resident, directly contradicting manufacturer safety instructions that warn this practice "could cause the lift to tip and endanger the resident and assistants."
Unsecured Hazardous Areas: The facility left keys in a janitor's closet door containing cleaning chemicals, and failed to lock the beauty shop on the secure unit when unattended, creating potential access to hazardous equipment and substances for residents with dementia.
Infection Control Lapses: A nursing assistant was observed feeding residents without proper hand hygiene, placing hands on clothing and between knees before handling feeding utensils and touching multiple residents.
Waste Management Problems: The facility's dumpster area contained scattered medical waste, used gloves, and debris around the grounds, with broken fencing that failed to contain refuse properly.
Failure to Report Incidents: The facility did not report the pattern of resident-to-resident altercations to state authorities as required by regulations, with the administrator stating only incidents resulting in injury needed reporting.
The Centers for Medicare & Medicaid Services removed the immediate jeopardy status on January 31, 2025, after the facility implemented corrective measures including placing Resident #44 on one-on-one supervision, discharging the aggressive resident, and providing staff training on behavior management and care plan compliance.
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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