Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westwood Health And Rehab, Inc during CMS and state inspections, most recent first.
The facility failed to report two residents’ hospital transfers to the ombudsman. One resident had severe cognitive impairment with dementia, psychotic and mood disturbances, and anxiety, while the other had severe cognitive impairment with acute respiratory failure, morbid obesity, DM2, anxiety, and anoxic brain damage. Both residents were discharged to hospitals, but neither was listed on the facility’s transfer reports sent to the ombudsman, and the Administrator confirmed they should have been included.
A facility failed to implement an effective care plan for a resident with wandering behaviors, leading to multiple incidents of resident-to-resident aggression. The resident, diagnosed with dementia, experienced physical aggression from other residents, resulting in a broken hip. Despite the resident's impaired cognitive skills and behavior symptoms, the care plan lacked adequate measures to prevent altercations. Staff interviews revealed insufficient interventions and monitoring, contributing to the repeated incidents.
A resident with dementia experienced repeated abuse from other residents, including a severe incident resulting in a fractured hip. Despite known aggressive tendencies of one resident and the wandering behavior of the victim, the facility's interventions were inadequate. Staff interviews revealed insufficient monitoring and ineffective implementation of care plans, leading to multiple incidents of physical aggression.
A resident with dementia was pushed by another resident, resulting in a hip fracture. Despite the severity of the injury, the facility did not report the incident to the State Agency within the required 24-hour timeframe. The facility's administrator was unaware of the regulation requiring the reporting of all resident-to-resident altercations, leading to a failure in compliance.
A resident with a history of cerebrovascular disease and atrial fibrillation showed signs of a stroke, including slurred speech and left-sided weakness. Despite these symptoms, there was a delay of approximately four hours before the resident was sent to the emergency room, resulting in ineligibility for thrombolysis. The facility failed to promptly notify the resident's primary care provider and follow its policy on changes in a resident's condition.
A LTC facility failed to ensure safety and supervision, leading to multiple deficiencies. A resident with hemiplegia was improperly lifted after a fall, and keys were left in a janitor's closet door, exposing residents to hazardous chemicals. Staff incorrectly used a mechanical lift, risking resident safety, and the beauty shop was left unlocked with hazardous items accessible. These incidents highlight lapses in following safety protocols and maintaining a secure environment.
The facility failed to properly dispose of garbage and refuse, as observed with open dumpster gates exposing waste items and debris scattered around the area. The Dietary Manager admitted to checking the dumpster area three times a week but acknowledged the presence of a black trash bag on the ground for a week. The DM also noted the lack of training for dietary employees on refuse disposal. The facility's policy requires dumpsters to be closed and free of litter.
The facility did not maintain a current CLIA certificate for the level of testing performed, as required by CMS regulations. The CLIA certificate had expired, and the Administrator was unable to provide an updated certificate during the survey, despite a payment confirmation for the license.
The facility failed to ensure proper hand hygiene during a meal service. An NA was observed rubbing their hands on their shirt, placing them in their lap, and feeding a resident without sanitizing their hands. This behavior was repeated, and the NA also adjusted a second resident before offering a drink to the first resident without performing hand hygiene. The NA acknowledged the oversight, and the DON confirmed the actions were inappropriate.
Failure to Report Resident Transfers to the Ombudsman
Penalty
Summary
The facility failed to ensure that resident transfers or discharges were reported to the ombudsman for two residents reviewed. One resident had diagnoses including muscle wasting and atrophy, acute respiratory failure with hypoxia, moderate dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and had a BIMS score of 3 indicating severe cognitive impairment. The resident was admitted on 03/27/2025 and later discharged to a local hospital, but was not listed on the facility’s Emergency Transfers report sent to the ombudsman for April 2025. A second resident had diagnoses including acute respiratory failure with hypoxia, morbid obesity due to excess calories, type 2 diabetes mellitus, anxiety disorder, and anoxic brain damage, and had a BIMS score of 7 indicating severe cognitive impairment. This resident was admitted on 01/31/2025 and discharged to an area hospital, but was not listed on the facility’s Emergency Transfers report sent to the ombudsman for February 2025. During interview, the Administrator stated the Business Office Manager was responsible for preparing the discharge/transfer list and confirmed that both residents should have been included in the reports sent to the ombudsman; the Administrator also stated that except for residents discharged home, all transfers were reported to the ombudsman.
Failure to Implement Effective Care Plan for Resident with Wandering Behaviors
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan for a resident with wandering behaviors, who was at risk for resident-to-resident altercations. This deficiency was identified for a resident who had multiple incidents of physical aggression received from other residents. The incidents occurred on a locked unit, where the resident was pushed, kicked, hit, and punched by other residents, resulting in a broken hip during the last incident. The care plan lacked effective interventions to monitor and address the resident's wandering behavior and the risk of altercations. The resident, who had a diagnosis of dementia with agitation, disorientation, insomnia, restlessness, and agitation, was admitted to the facility and required a secured/special care neighborhood. Despite the resident's moderately impaired cognitive skills and physical behavior symptoms directed towards others, the care plan did not include adequate measures to prevent altercations. The facility's interventions, such as encouraging the resident to fold laundry or take care of a baby doll, were insufficient to address the resident's wandering into other residents' rooms, which led to altercations. Interviews with staff revealed that the resident was not aggressive but had a tendency to take things from other residents, which agitated them and resulted in physical aggression towards the resident. Staff were aware of the resident's behavior but failed to implement effective interventions, such as one-on-one observation, as outlined in the care plan. The facility's inability to substantiate the allegations of abuse and the lack of appropriate interventions contributed to the repeated incidents of resident-to-resident aggression.
Removal Plan
- Resident #44 who received physical aggression placed on observation 1:1 by facility staff.
- Resident #9 who initiated physical aggression discharged from the facility.
- DON/Designee will initiate an in-service on all staff currently in facility on handling residents with behaviors and continue training staff as they clock in until all staff have been trained.
- DON/Designee will initiate in-service related to following care plan interventions for direct care staff currently in facility. Direct care staff not present will be in-serviced prior to the start of their shift. Any newly hired direct care staff will also be in-serviced.
- DON/Designee will review all care plans for residents residing in the Dementia care unit for appropriate interventions related to behaviors and update the care plans as needed.
- Nurse Consultant/Designee will initiate in-service with the Minimum Data Set (MDS) coordinator and all nurse managers on reviewing and updating care plans and that interventions are appropriate and effective.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from repeated instances of resident-to-resident abuse, resulting in significant harm. Resident #44, who had a history of dementia with agitation and was moderately cognitively impaired, experienced multiple incidents of physical aggression from other residents. These incidents included being hit, pushed, and punched, leading to a fractured hip after being pushed by Resident #9. Despite the resident's known tendency to wander into other residents' rooms, the facility's interventions were insufficient to prevent these occurrences. Resident #9, who also had severe cognitive impairments and a history of autism and schizophrenia, was identified as the aggressor in several incidents. The facility's care plan for Resident #9 included monitoring and medication adjustments, but these measures were inadequate to prevent aggressive behavior. The facility's incident reports documented multiple instances where Resident #9 physically assaulted Resident #44, yet the facility did not substantiate these as abuse due to the cognitive impairments of the residents involved. Interviews with staff revealed a lack of effective monitoring and intervention strategies. Staff members were aware of the aggressive tendencies of Resident #9 and the wandering behavior of Resident #44, but the measures in place, such as staff presence in the hallway and monitoring via cameras, were not effectively implemented. The facility's failure to provide adequate supervision and intervention led to repeated abuse incidents, culminating in a serious injury to Resident #44.
Removal Plan
- Resident #44 who received physical aggression placed 1:1 observation by facility staff.
- Resident #9 who initiated physical aggression discharged facility.
- Licensed nurse will assess all residents currently on secured unit for signs and symptoms of physical aggression as well as assess for signs of trauma and physical abuse by skin audits.
- DON/Designee will initiate an in-service on all staff currently in facility on handling residents with behaviors as well as Dementia training. Staff not present will be in-serviced prior to the start of their shift.
Failure to Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to report a resident-to-resident altercation within the required 24-hour timeframe, even though it resulted in a serious injury. On January 8, 2025, Resident #9 pushed Resident #44 into a wall, causing Resident #44 to grab their hip in pain. This incident occurred in the Alzheimer's unit, and Resident #44 was later diagnosed with a hip fracture. Despite the severity of the injury, the facility's investigation concluded that the incident could not be substantiated as abuse due to the cognitive impairments of both residents involved. However, the State Operations Manual Appendix PP, F600, clarifies that willful actions, such as shoving, are considered deliberate or non-accidental, regardless of the resident's mental capacity. Resident #44 had a history of dementia with agitation and exhibited behaviors such as wandering and physical aggression. The resident's care plan included interventions for these behaviors, but the facility did not report the incident to the State Agency as required. The facility's administrator was unaware of the regulation mandating the reporting of all resident-to-resident altercations, regardless of the outcome. This oversight resulted in only one of several incidents involving Resident #44 being reported to the State Agency over the past year.
Delayed Response to Stroke Symptoms in Resident
Penalty
Summary
The facility failed to provide prompt treatment for a resident who exhibited signs of a stroke, resulting in a delay of approximately four hours before the resident was sent to the emergency room. The resident, who had a history of neurocognitive disorder with Lewy bodies, chronic obstructive pulmonary disease, atrial fibrillation, and cerebrovascular disease, showed symptoms such as slurred speech and left-sided weakness. Despite these symptoms, the resident was not immediately evaluated by a physician, and the delay in treatment meant that the resident was not eligible for intravenous thrombolysis upon hospital admission. The resident's care plan included monitoring for side effects of anticoagulant medication due to the risk of blood clots. On the day of the incident, staff noticed the resident acting strangely and reported slurred speech during a smoke break. The LPN on duty requested a doctor to see the resident during rounds, but the resident was allowed to rest instead of being sent for immediate evaluation. The APRN later conducted a telecommunication assessment and recommended that the resident be sent to the emergency room due to the possibility of a stroke. There was a lack of documentation regarding the physician's involvement on the day of the incident. The Director of Nursing reported receiving a call from the resident's Medical Physician, who allegedly saw the resident and discussed care plans, but the physician later denied seeing the resident that day. The facility's policy on changes in a resident's condition requires prompt notification of the resident's primary care provider and representative, which was not adequately followed in this case.
Multiple Safety and Supervision Failures in LTC Facility
Penalty
Summary
The facility failed to properly transfer a resident with hemiplegia and hemiparesis following a cerebral infarction. The resident, who was cognitively intact and able to transfer independently, was found on the floor after attempting to transfer to a wheelchair without proper footwear. Staff improperly lifted the resident by placing their hands under the resident's arms instead of using a gait belt, which could have resulted in a shoulder injury. The facility's policy did not specify the correct procedure for transferring residents after a fall. In another incident, the facility did not ensure the security of hazardous materials. A housekeeping supervisor left keys in the door of a janitor's closet, which contained various cleaning chemicals, creating a potential hazard for residents. The supervisor was unaware of the oversight until informed by a surveyor, highlighting a lapse in maintaining a safe environment for residents. Additionally, the facility failed to follow proper procedures when using a mechanical lift for a resident with dementia and other conditions requiring total care. Staff locked the rear casters of the lift during a transfer, contrary to the manufacturer's instructions, which could lead to the lift tipping. The facility's policy did not address this specific safety measure. Furthermore, the beauty shop on a secured unit was left unlocked and unattended, with potentially hazardous items accessible to residents, due to the beautician not having a key.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a survey. The trash dumpster gates were left open, exposing trash bags containing various waste items such as briefs and gloves. Additionally, a used recliner and broken wooden fencing were found next to the dumpster. The fence surrounding the dumpster was missing a large section, revealing a large black trash bag on the ground, which was torn open with debris spilling out. Various items, including used gloves, paper, and other debris, were scattered around the dumpster area. A white bag of used rolled baby diapers was also found on the ground along the facility's back fence. Interviews with the facility's Administrator and Dietary Manager (DM) revealed that the dietary department was responsible for maintaining the dumpster area. The DM admitted to checking the dumpster three times a week and acknowledged that the black trash bag had been on the ground since the previous week. The DM also noted that the dumpster gates were always left open and that the dumpster door should be closed. The DM expressed concerns about the potential danger posed by the gloves and brush to residents. The DM also stated that there was no training documentation or in-services provided to dietary employees regarding refuse disposal. The facility's policy on garbage disposal, revised in 2017, indicated that garbage should be stored in a manner inaccessible to pests and that dumpsters should be kept closed and free of surrounding litter.
Expired CLIA Certificate for Laboratory Testing
Penalty
Summary
The facility failed to maintain a current Clinical Laboratory Improvement Amendment (CLIA) certificate appropriate for the level of testing performed within the facility. During a review, it was observed that the facility's CLIA certificate had expired on January 25, 2025. When questioned, the Administrator acknowledged the absence of a current certificate and indicated the need to retrieve it. Although a payment confirmation for the CLIA license was noted, the facility was unable to provide an updated certificate at the time of the survey.
Failure in Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure proper hand hygiene during a meal service, as observed on January 27, 2025. Nursing Assistant (NA) #9 was seen rubbing their hands on their shirt, placing them in their lap, and then feeding a resident without sanitizing their hands. This behavior was repeated as NA #9 placed their hands between their knees, then fed the resident again without sanitizing. Additionally, NA #9 reached across a second resident to adjust them and then offered a drink to the first resident without performing hand hygiene. During an interview, NA #9 acknowledged the bad habit of placing hands between the knees and confirmed that hand sanitization should have occurred before feeding the residents after touching clothes or moving between residents. The Director of Nursing (DON) confirmed that the actions observed were inappropriate and that hand sanitization should have been performed between assisting different residents.
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What surveyors actually found near you
We read the 64 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Springdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Springdale Health And Rehabilitation Center | 1 mi | ★★★★★ | 13 | 0 |
| Windcrest Health And Rehab Inc | 2.1 mi | ★★★★★ | 0 | 0 |
| Edgewood Health And Rehab | 2.5 mi | ★★★★★ | 0 | 0 |
| Shiloh Nursing And Rehab, Llc | 3 mi | ★★★★★ | 0 | 0 |
| The Maples At Har-ber Meadows | 3.1 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.