Westwood Health and Rehab: Ombudsman Reporting Failure - AR
That omission sat undiscovered for months. It surfaced during a complaint inspection on May 28, 2026, when federal inspectors reviewed four months of emergency transfer logs and found the resident, identified in inspection records as Resident 3, absent from every one of them.
The logs covered February, March, April, and May of 2025. Resident 3's name appeared on none of them.
The facility's administrator confirmed the gap directly. During an interview at 11:25 a.m. on the day of the inspection, the administrator acknowledged that Resident 3 should have been on the February 2025 list. The administrator said the facility's practice was to report all transfers to the ombudsman except for residents who discharged home. An emergency department transfer for a resident not expected to return, the administrator said, should have been included.
It wasn't.
The state long-term care ombudsman program exists specifically to advocate for nursing home residents who cannot advocate for themselves. Inspectors noted that both Resident 1 and Resident 3 were dependent on the facility for communication because of cognitive deficits. Resident 3's cognitive impairment score was a 7, which inspectors characterized as indicating severe cognitive impairment.
A resident who cannot communicate independently, who is transferred to a hospital and not expected to come back, is precisely the kind of person the ombudsman reporting system is designed to protect. Someone needs to know she left. Someone outside the facility needs to be able to check.
Nobody outside the facility was told.
The inspection report rated the level of harm as potential for minimal harm, the lowest tier on the federal scale. That classification reflects what inspectors could document, not necessarily what a resident in that position experienced. A woman with severe cognitive impairment, transferred to an emergency department, not expected to return to the only place she had been living, with no external advocate notified of her departure, is not a paperwork problem.
The administrator's explanation raised its own questions. If the facility's stated policy was to report all transfers except discharges home, and if an emergency transfer for a resident not expected to return clearly did not qualify as a discharge home, then the omission was not a matter of ambiguity. The administrator did not offer an explanation for why the transfer was missed, only that it should not have been.
Inspectors also reviewed a facility policy on resident rights, revised in December 2016, which stated that residents have the right to communicate with outside agencies, including state and federal officials, surveyors, the long-term care ombudsman, and protection and advocacy organizations. For residents who can make phone calls, write letters, or ask a family member to intervene, that right has practical meaning. For residents like Resident 3, whose severe cognitive impairment made independent communication impossible, the right exists on paper. Its exercise depended entirely on the facility acting as an intermediary.
The facility did not act as that intermediary. Not for Resident 3's February 2025 transfer.
Inspectors found the violation affected some residents, not just one. The inspection report identified both Resident 1 and Resident 3 as cognitively impaired and dependent on the facility for outside communication, though the specific reporting failure documented in detail involved Resident 3.
The administrator, when presented with the finding, confirmed it. There was no dispute about what had happened. The February 2025 list went to the ombudsman without Resident 3's name on it, and by the time anyone looked closely enough to notice, more than a year had passed.
Where Resident 3 went after that February transfer, and what happened to her, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westwood Health and Rehab, Inc from 2026-05-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
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 20, 2026 · Our methodology
WESTWOOD HEALTH AND REHAB, INC in SPRINGDALE, AR was cited for violations during a health inspection on May 28, 2026.
That omission sat undiscovered for months.
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.