Arlington Heights Health Center: Jeopardy Citation TX
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.
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
Arlington Heights Health and Rehabilitation Center in Fort Worth, TX was cited for violations during a health inspection on February 15, 2025.
The resident in question possessed baby dolls with hard plastic heads, which became weapons during aggressive episodes.
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.