FORT WORTH, TX - Arlington Heights Health and Rehabilitation Center was cited for immediate jeopardy to resident safety following multiple incidents of resident-to-resident altercations and failure to provide adequate ostomy care, according to a February 15 federal inspection report.
Serious Safety Violations Lead to Emergency Intervention
The inspection revealed that one resident with behavioral issues repeatedly engaged in physical altercations with other residents and staff, creating an unsafe environment that warranted the facility's most serious citation level. The situation became so concerning that federal inspectors classified it as "immediate jeopardy," meaning residents faced immediate risk of serious injury or death.
The resident in question possessed baby dolls with hard plastic heads, which became weapons during aggressive episodes. Despite documented behavioral issues, the facility failed to implement adequate interventions to prevent these dangerous situations from occurring repeatedly.
Federal inspectors documented that the resident was "immediately placed on 1:1 supervision" and ultimately transferred to another facility on February 11, 2025, the same day the inspection team arrived. The baby dolls were confiscated from the resident's room as part of emergency safety measures.
Breakdown in Communication and Supervision
The inspection revealed systemic failures in how staff responded to aggressive behaviors and coordinated care. The facility's approach to managing residents with behavioral challenges proved inadequate, allowing dangerous situations to escalate without proper intervention.
Federal regulations require nursing homes to maintain environments free from abuse and neglect, including preventing resident-to-resident altercations. When residents exhibit aggressive behaviors, facilities must implement comprehensive care plans with specific interventions, ensure adequate staffing supervision, and train all staff on appropriate response protocols.
The immediate jeopardy citation indicates inspectors found the facility's failures posed a direct threat to resident safety. This classification triggers mandatory federal oversight and requires immediate corrective action before the facility can continue normal operations.
Colostomy Care Failures Put Vulnerable Resident at Risk
A separate but equally concerning violation involved inadequate ostomy care for a legally blind resident with cognitive impairment. The resident required assistance with her colostomy bag due to her visual limitations and stroke-related paralysis affecting the right side of her body.
During the evening of February 7, 2025, the resident's colostomy bag began leaking. She called for help using her call light system, but received inadequate assistance from nursing staff. According to the resident's account, a certified nursing assistant told her he would need to get the nurse for help.
The licensed vocational nurse who responded informed the resident she could not provide assistance because she was monitoring the evening meal in the dining area. The nurse placed a new colostomy bag on the resident's bedside table and left without ensuring the resident received proper care.
The resident waited approximately 20 minutes for assistance that never came. Despite her visual impairment and physical limitations, she attempted to change the colostomy bag herself. Due to improper application, the bag began leaking again later that evening, requiring intervention from night shift staff.
Medical Implications of Ostomy Care Failures
Proper ostomy care is critical for preventing serious medical complications. When colostomy bags leak, fecal matter comes into direct contact with the surrounding skin, creating immediate risks for irritation, inflammation, and potentially serious skin breakdown.
For residents with compromised immune systems or diabetes, skin breakdown can lead to dangerous infections that may become life-threatening. The facility's own policy acknowledges that "persistent leakage or poorly fitted appliances can cause injury to the stoma and skin breakdown."
Residents with visual impairments and physical limitations cannot safely manage ostomy care independently. Federal regulations require facilities to provide comprehensive assistance with activities of daily living based on each resident's specific needs and limitations.
The facility's Director of Nursing acknowledged during interviews that skin exposure to fecal matter "could quickly lead to skin irritation and skin breakdown," demonstrating awareness of the risks while failing to ensure adequate care protocols.
Staffing Coordination Failures
The inspection revealed significant breakdowns in communication between nursing staff. The evening nurse who refused to help with ostomy care cited her responsibility to monitor the dining area, but failed to notify the second nurse on duty about the resident's immediate needs.
When inspectors interviewed the second nurse, she stated this was the first time she had heard about the situation. The facility employed two nurses during evening shifts specifically to ensure adequate coverage, but coordination between staff proved inadequate.
The Director of Nursing told inspectors his expectation was that nurses unable to assist residents immediately should communicate with teammates and ensure coverage. This basic coordination protocol was not followed, leaving a vulnerable resident without necessary care.
Emergency Response and Corrective Actions
Following the immediate jeopardy citation, the facility implemented several emergency measures. All staff received mandatory training on abuse prevention, behavior management, and appropriate response protocols. Staff members who missed the training were prohibited from working until completing the education requirements.
The facility's administrator and Director of Nursing received specialized training from a regional compliance nurse on abuse prevention and behavior management policies. An emergency quality assurance meeting was convened to address the safety violations and develop prevention strategies.
Federal inspectors verified that comprehensive staff education was completed, with all employees demonstrating understanding of abuse prevention protocols, signs of aggressive behavior, and appropriate intervention strategies. The immediate jeopardy status was removed on February 13, 2025, though the facility remained under increased scrutiny.
Industry Standards and Best Practices
Federal regulations require nursing homes to maintain comprehensive care plans for residents with behavioral challenges, including specific interventions, environmental modifications, and staff training protocols. Facilities must assess residents regularly and update care plans when behaviors change or escalate.
For ostomy care, industry standards mandate that residents receive assistance based on their individual capabilities and limitations. Facilities must ensure adequate staffing to provide timely assistance with personal care needs, particularly for residents with sensory impairments or cognitive limitations.
The Centers for Medicare & Medicaid Services expects nursing homes to maintain communication systems that ensure continuity of care across all shifts and departments. When staff cannot immediately respond to resident needs, protocols must exist for appropriate delegation and follow-up.
Additional Issues Identified
Beyond the major violations, the inspection documented concerns about the facility's overall approach to resident safety and quality assurance. The transfer of the aggressive resident to another facility, while necessary for immediate safety, highlighted the need for better initial assessment and care planning to prevent such situations.
The facility's policies regarding ostomy care dated back to 2003, suggesting potential gaps in current best practices and updated protocols. Modern ostomy care standards emphasize patient education, family involvement, and comprehensive staff training to ensure optimal outcomes.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Arlington Heights Health and Rehabilitation Center from 2025-02-15 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.