Westwood Health & Rehab: Safety Violations, AR
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.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
WESTWOOD HEALTH AND REHAB, INC in SPRINGDALE, AR was cited for violations during a health inspection on January 31, 2025.
The incidents escalated on January 8, 2025, when another resident pushed Resident #44 into a wall, causing a hip fracture that required emergency surgery.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.