Deficiencies (last 3 years)
Deficiencies (over 3 years)
16 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
208% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jan 31, 2025
Visit Reason
The inspection was conducted due to complaints and allegations of resident-to-resident abuse and failure to ensure proper care and reporting of incidents, including a resident sustaining a fractured hip from abuse and concerns about care plan adequacy and timely treatment of residents.
Complaint Details
The complaint investigation focused on allegations of resident-to-resident abuse involving Resident #44 and Resident #9, including multiple incidents of physical aggression resulting in serious injury to Resident #44. The facility's failure to protect residents, timely report incidents, and provide adequate care plans were substantiated. Additionally, concerns about delayed treatment for Resident #112 and lack of current CLIA certification were identified.
Findings
The facility failed to protect residents from abuse, specifically resident-to-resident physical aggression involving Resident #44 and Resident #9, resulting in serious injury including a fractured hip. The facility also failed to timely report incidents, ensure comprehensive care plans with effective interventions, and provide prompt treatment for a resident showing stroke symptoms. Additionally, the facility lacked a current CLIA certificate for laboratory testing.
Deficiencies (5)
Failure to protect Resident #44 from resident-to-resident abuse resulting in serious injury including a fractured hip.
Failure to timely report resident-to-resident events within 24 hours for Resident #9.
Failure to develop and implement a comprehensive person-centered care plan with effective interventions for Resident #44 at risk for resident-to-resident altercations.
Failure to provide prompt treatment after noticing a change in condition for Resident #112 showing signs of stroke.
Failure to maintain a current Clinical Laboratory Improvement Amendment (CLIA) certificate appropriate for the level of testing performed.
Report Facts
Physical aggression incidents: 10
Staff interviews conducted: 30
Staff trained: 45
Staff interviews regarding care plans: 6
CLIA certificate expiration date: Jan 25, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #13 | CNA | Interviewed regarding Resident #44's behavior and incidents |
| Certified Nursing Assistant #2 | CNA | Interviewed regarding altercation between Resident #44 and Resident #9 |
| Certified Nursing Assistant #1 | CNA | Interviewed regarding monitoring and behavior of Resident #9 and Resident #44 |
| Director of Nursing | DON | Interviewed regarding Resident #44's hospital transfer and facility interventions |
| Licensed Practical Nurse #12 | LPN | Interviewed regarding incident between Resident #44 and Resident #9 and care plan interventions |
| Administrator | Administrator | Interviewed regarding facility interventions and reporting |
| Registered Nurse #14 | RN | Documented Resident #112's condition and notification of emergency room transfer |
| Advanced Practice Registered Nurse | APRN | Provided telehealth evaluation for Resident #112 on 10/03/2024 |
| Medical Physician | MP | Interviewed regarding rounds and care of Resident #112 |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Jan 31, 2025
Visit Reason
The inspection was conducted due to complaints and allegations of abuse, neglect, and failure to provide adequate care and supervision to residents, including failure to report resident-to-resident abuse and failure to provide prompt treatment after a change in condition.
Complaint Details
The complaint investigation was substantiated with findings that the facility failed to timely report resident-to-resident abuse, failed to implement effective care plans, and failed to provide prompt treatment for a resident with stroke symptoms, among other deficiencies.
Findings
The facility failed to timely report resident-to-resident abuse, failed to develop and implement effective care plans for residents with wandering and aggressive behaviors, failed to provide prompt treatment for a resident showing stroke symptoms, failed to ensure safe transfer and supervision practices, left hazardous areas unsecured, improperly disposed of garbage and refuse, and failed to ensure proper hand hygiene during meal service.
Deficiencies (9)
Failed to timely report resident-to-resident abuse within 24 hours for Resident #9 resulting in a hip fracture.
Failed to develop and implement a comprehensive person-centered care plan with measurable objectives for Resident #44, resulting in multiple resident-to-resident abuse incidents and immediate jeopardy.
Failed to provide prompt treatment for Resident #112 showing signs of stroke, delaying emergency room transfer by approximately 4 hours.
Failed to properly transfer Resident #41 after a fall, picking resident up without using a gait belt, risking injury.
Failed to ensure keys were not left unattended in janitor closet door where chemicals were stored.
Failed to ensure rear casters/wheels of mechanical lift were in unlocked position when raising and lowering Resident #8, risking tipping.
Failed to ensure beauty shop on secured unit was locked when not in use or when no staff present.
Failed to properly dispose of garbage and refuse, leaving dumpster gates open, trash exposed, and debris scattered around dumpster area.
Failed to ensure hand hygiene was performed during meal service; Nursing Assistant fed residents without sanitizing hands after touching clothes and other residents.
Report Facts
Residents reviewed for abuse and neglect: 3
Physical aggression incidents for Resident #44: 10
Staff trained on behavior interventions: 45
Staff interviewed for training verification: 30
Staff interviewed regarding care plans: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #13 | CNA | Mentioned in relation to Resident #44 behavior and hospital transfer |
| Certified Nursing Assistant #2 | CNA | Reported on altercation involving Resident #44 |
| Certified Nursing Assistant #1 | CNA | Observed Resident #44 behavior and staff monitoring |
| Licensed Practical Nurse #12 | LPN | Provided statements about Resident #44 interventions and hospital transfer |
| Director of Nursing | DON | Interviewed regarding Resident #44 care plan, abuse reporting, and training |
| Administrator | Administrator | Interviewed regarding abuse reporting, care plans, and beauty shop security |
| Medical Records Coordinator | Involved in picking up Resident #41 after fall | |
| Housekeeping Supervisor | Left keys in janitor closet door | |
| Dietary Manager | DM | Responsible for dumpster area and refuse disposal |
| Nursing Assistant #9 | NA | Observed failing to perform hand hygiene during meal service |
| Registered Nurse #14 | RN | Notified on Resident #112 condition and emergency room transfer |
| Advanced Practice Registered Nurse | APRN | Provided telehealth evaluation for Resident #112 |
| Medical Physician | MP | Involved in Resident #112 care and communication with DON |
| Beautician | Left beauty shop door open without key |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jan 31, 2025
Visit Reason
The inspection was conducted due to complaints and allegations of resident-to-resident abuse and neglect, including physical aggression incidents involving residents in a secured dementia care unit.
Complaint Details
The complaint investigation focused on allegations of resident-to-resident abuse involving Resident #44 and Resident #9, including physical aggression incidents resulting in injury. The facility was found non-compliant with abuse prevention and care planning requirements. The investigation also included review of delayed reporting of incidents and delayed medical treatment for Resident #112.
Findings
The facility failed to protect residents from resident-to-resident abuse, resulting in multiple incidents of physical aggression toward Resident #44, culminating in a fractured hip. The facility also failed to timely report some incidents to the State Agency and did not have an adequate comprehensive care plan with effective interventions for residents with wandering and aggressive behaviors. Additionally, the facility delayed prompt treatment for Resident #112 showing stroke symptoms and lacked a current CLIA certificate for laboratory testing.
Deficiencies (5)
Failed to protect Resident #44 from resident-to-resident abuse resulting in multiple physical aggression incidents including a fractured hip.
Failed to timely report resident-to-resident events to the State Agency as required.
Failed to develop and implement a comprehensive person-centered care plan with effective interventions for Resident #44's wandering and aggressive behaviors.
Failed to provide prompt treatment and care for Resident #112 after noticing signs of stroke, delaying emergency room transfer by approximately 4 hours.
Failed to maintain a current Clinical Laboratory Improvement Amendment (CLIA) certificate appropriate for the level of testing performed.
Report Facts
Physical aggression incidents: 10
Staff trained: 45
Total staff: 105
Staff interviews: 30
Staff interviews on care plans: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #13 | Certified Nursing Assistant | Interviewed regarding Resident #44's behavior and incidents of abuse. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed about monitoring and altercation between Resident #44 and Resident #9. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed about Resident #9's behaviors and staff monitoring during incidents. |
| Director of Nursing | Director of Nursing | Interviewed about interventions, care plans, and staff training related to resident behaviors. |
| Licensed Practical Nurse #12 | Licensed Practical Nurse | Interviewed regarding Resident #44's behaviors and incident details. |
| Administrator | Administrator | Interviewed about facility interventions, staff training, and reporting requirements. |
| Registered Nurse #14 | Registered Nurse | Documented and reported Resident #112's change in condition and emergency room transfer. |
| Advanced Practice Registered Nurse | APRN | Provided telehealth evaluation for Resident #112 and ordered emergency room transfer. |
| Medical Physician | Medical Physician | Involved in Resident #112's care and communication with Director of Nursing. |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Jan 31, 2025
Visit Reason
The inspection was conducted due to complaints and allegations of resident-to-resident abuse, failure to report incidents timely, inadequate care planning for residents with wandering and aggressive behaviors, delayed treatment for a resident showing stroke symptoms, and safety hazards in the facility environment.
Complaint Details
The complaint investigation was substantiated with findings that the facility failed to timely report resident-to-resident abuse, failed to implement adequate care plans for residents with aggressive behaviors, delayed treatment for a resident with stroke symptoms, and had multiple safety and infection control deficiencies.
Findings
The facility failed to timely report resident-to-resident abuse incidents, develop and implement effective care plans for residents with wandering and aggressive behaviors, provide prompt treatment for a resident showing stroke symptoms, ensure safe transfer and supervision practices, maintain secure hazardous areas, properly dispose of garbage and refuse, and enforce infection control practices during meal service.
Deficiencies (9)
Failure to timely report resident-to-resident abuse incidents within 24 hours.
Failure to develop and implement a comprehensive person-centered care plan with measurable objectives for a resident with wandering and aggressive behaviors, resulting in multiple incidents of resident-to-resident abuse and a broken hip.
Failure to provide prompt treatment and emergency evaluation for a resident showing signs of stroke, resulting in delayed hospital admission and treatment.
Improper transfer technique of a resident after a fall, risking injury by lifting without a gait belt.
Keys left unattended in janitor closet door where chemicals were stored, posing a hazard.
Mechanical lift rear casters/wheels improperly locked during resident transfer, contrary to manufacturer recommendations.
Beauty shop door left unlocked and open without staff present, exposing residents to potential hazards.
Dumpster gates and door left open, garbage and refuse improperly disposed of with trash and hazardous items scattered around the area.
Failure to perform hand hygiene during meal service, increasing risk of infection transmission.
Report Facts
Residents reviewed for abuse: 3
Physical aggression incidents: 10
Staff interviews conducted: 30
Staff trained in behavior interventions: 45
Residents reviewed for accidents: 9
Dumpster inspections per week: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #9 | Nursing Assistant | Observed failing to perform hand hygiene during meal service |
| Director of Nursing | Director of Nursing | Interviewed regarding abuse reporting, care plans, mechanical lift use, and infection control |
| Administrator | Administrator | Interviewed regarding abuse reporting, beauty shop security, and dumpster area |
| Certified Nursing Assistant #11 | Certified Nursing Assistant | Assisted in improper transfer of Resident #41 after fall |
| Medical Records Coordinator | Medical Records Coordinator | Assisted in improper transfer of Resident #41 after fall |
| Licensed Practical Nurse #12 | Licensed Practical Nurse | Interviewed regarding delayed treatment of Resident #112 and resident-to-resident interactions |
| Certified Nursing Assistant #7 | Certified Nursing Assistant | Observed locking mechanical lift casters improperly during transfer of Resident #8 |
| Certified Nursing Assistant #8 | Certified Nursing Assistant | Observed locking mechanical lift casters improperly during transfer of Resident #8 |
| Dietary Manager | Dietary Manager | Interviewed regarding dumpster area maintenance and refuse disposal |
| Beautician | Beautician | Interviewed regarding beauty shop door left unlocked |
Inspection Report
Routine
Deficiencies: 8
Date: Jan 25, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, safety, and facility conditions.
Findings
The facility was found deficient in multiple areas including failure to provide weighted cups for hydration to a cognitively impaired resident, failure to post required contact information in the secure unit, unsafe resident room conditions, inadequate personal hygiene care for residents, failure to provide an ongoing activities program in the secure unit, unsafe storage of hazardous fluids in resident rooms, and failure to properly date and store oxygen equipment for residents on oxygen therapy.
Deficiencies (8)
Failure to provide weighted cup for fluids to prevent dehydration for Resident #13.
Failure to post contact information for State agencies and advocacy groups in the secure unit accessible to residents.
Failure to maintain resident rooms in a safe, functional, homelike manner due to disconnected trim and unsafe built-in drawers in 3 rooms.
Failure to provide adequate personal hygiene care including fingernail care and shaving for multiple residents.
Failure to provide an ongoing program of activities for 15 residents in the secure unit.
Failure to ensure hazardous fluids were stored safely in resident rooms in the secure unit.
Failure to ensure fluids were always available for hydration for Resident #13.
Failure to ensure oxygen tubing, humidifier mask, and water bottle were dated and properly stored for Residents #3 and #13.
Report Facts
Residents affected: 1
Residents affected: 15
Rooms affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 15
Residents affected: 10
Residents affected: 12
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #2 | Mentioned in relation to Resident #13 hydration deficiency and Resident #105 shaving deficiency | |
| Licensed Practical Nurse #1 | Interviewed about oxygen tubing dating and cleaning under nails | |
| Director of Nursing | Director of Nursing | Interviewed regarding posting requirements and follow-up on nail care |
| Administrator | Administrator | Confirmed posting requirements and hazardous fluid storage policies |
| Maintenance Supervisor #1 | Acknowledged and planned repairs for room trim and drawers | |
| Activity Director | Mentioned in relation to Resident #13 hydration deficiency and activities program | |
| Social Worker | Mentioned in relation to Resident #13 hydration deficiency | |
| Director of Activities | Confirmed responsibility for activities program in secure unit |
Inspection Report
Routine
Deficiencies: 8
Date: Jan 25, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations at Westwood Health and Rehab, Inc.
Findings
The facility was found deficient in multiple areas including failure to provide weighted cups for hydration to a cognitively impaired resident, failure to post required contact information in the secure unit, unsafe and non-functional resident room conditions, inadequate personal hygiene care for several residents, failure to provide an ongoing activities program in the secure unit, unsafe storage of hazardous fluids in resident rooms, and failure to properly date and store oxygen equipment for residents on oxygen therapy.
Deficiencies (8)
Failure to provide weighted cup for fluids to prevent dehydration for Resident #13.
Failure to post contact information for State agencies and advocacy groups in the secure unit accessible to residents.
Failure to maintain resident rooms in a safe, functional, homelike manner due to disconnected trim and unsafe built-in drawers in 3 rooms.
Failure to provide adequate personal hygiene care including fingernail cleaning and shaving for multiple residents.
Failure to provide an ongoing program of activities for 15 residents in the secure unit.
Failure to ensure hazardous fluids were stored safely in resident rooms in the secure unit.
Failure to ensure fluids were always available for hydration for Resident #13.
Failure to ensure oxygen tubing, humidifier mask, and water bottle were dated and properly stored for Residents #3 and #13.
Report Facts
Residents affected: 1
Residents affected: 15
Rooms affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 15
Residents affected: 10
Residents affected: 12
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #2 | Mentioned in relation to Resident #13 hydration deficiency and Resident #105 shaving care | |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding posting of contact information, fingernail care, and hazardous fluid storage |
| Activity Director | Mentioned in relation to Resident #13 hydration deficiency and activities program | |
| Social Worker | Mentioned in relation to Resident #13 hydration deficiency | |
| Maintenance Supervisor #1 | Interviewed regarding room trim and drawer repairs | |
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Interviewed regarding oxygen tubing dating and cleaning under nails |
| Administrator | Administrator | Interviewed regarding posting of contact information, hazardous fluid storage, and activities program |
| Director of Activities | Interviewed regarding activities program in secure unit |
Inspection Report
Routine
Census: 66
Deficiencies: 2
Date: Oct 20, 2022
Visit Reason
The inspection was conducted to assess compliance with care standards related to personal hygiene and dietary safety practices at Westwood Health and Rehab, Inc.
Findings
The facility failed to ensure proper nail care for a diabetic resident, resulting in thick, jagged fingernails with a brownish substance, and failed to ensure dietary staff washed hands before handling clean equipment or food and promptly removed expired food items, potentially affecting multiple residents.
Deficiencies (2)
Failed to ensure a resident's fingernails were cleaned and trimmed to promote good personal hygiene and grooming.
Failed to ensure dietary staff washed their hands before handling clean equipment or food items and expired food items were promptly removed/discarded.
Report Facts
Residents affected: 1
Residents affected: 66
Expired food item date: May 3, 2022
Expired food item date: Sep 28, 2022
Expired food item date: Oct 17, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Performed nail care on Resident #17 and provided information about nail care responsibilities and risks |
| Certified Nurse Assistant #1 | Certified Nurse Assistant | Accompanied Surveyor to Resident #17's room and discussed nail care responsibilities |
| Dietary Employee #1 | Dietary Employee | Observed failing to wash hands before handling clean equipment and food |
| Dietary Employee #2 | Dietary Employee | Observed failing to wash hands before handling clean equipment and food |
Inspection Report
Routine
Census: 66
Deficiencies: 2
Date: Oct 20, 2022
Visit Reason
The inspection was conducted to assess compliance with care standards related to resident hygiene and dietary safety practices at Westwood Health and Rehab, Inc.
Findings
The facility failed to ensure proper nail care for a diabetic resident requiring assistance, resulting in minimal harm risk, and failed to ensure dietary staff washed hands properly and removed expired food items, posing potential foodborne illness risks to residents.
Deficiencies (2)
Failed to ensure a resident's fingernails were cleaned and trimmed to promote good personal hygiene and grooming for 1 of 7 sampled residents dependent on nail care.
Failed to ensure dietary staff washed their hands before handling clean equipment or food items and failed to promptly remove expired food items to prevent potential foodborne illness.
Report Facts
Residents affected: 7
Residents affected: 66
Residents affected: 21
Expiration date: May 3, 2022
Expiration date: Sep 28, 2022
Expiration date: Oct 17, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant (CNA) #1 | Described resident's nail condition and responsibility for nail care | |
| Licensed Practical Nurse (LPN) #1 | Performed nail care on resident and provided information about nail care responsibilities and risks | |
| Dietary Employee (DE) #1 | Observed failing to wash hands before handling clean equipment and food | |
| Dietary Employee (DE) #2 | Observed failing to wash hands before handling clean equipment and food | |
| Dietary Supervisor | Provided list of residents affected and facility hand washing policy |
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