Westwood Health & Rehab: Hip Fracture After Assault AR
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.
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.
Federal inspectors documented a troubling escalation of violence against the resident.
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.