Resident #213 had fallen four times in March alone. The facility's own care plan required the call pad to be placed on the bed's right side, where the resident typically falls, and within easy reach.
Instead, inspectors found it perched on medical equipment.
The complaint that triggered the state investigation alleged the nursing home wasn't implementing fall prevention measures for the resident. When inspectors arrived on October 7, they found the allegation was accurate.
During their first observation at 9:07 AM, the call pad was sitting on top of a suctioning container on the bedside table. The resident lay on the right side of the bed, unable to reach the device meant to summon help.
Six hours later, inspectors returned. The call pad still wasn't on the bed.
This time, the resident's family member was present. They told inspectors they had repeatedly observed the call pad placed out of reach. The family member showed inspectors a photograph taken three days earlier on October 4, documenting the call pad sitting on top of the oxygen humidifier machine.
The pattern was clear: basic safety equipment wasn't where it was supposed to be.
When inspectors summoned the Assistant Director of Nursing to the room and showed her the misplaced call pad, she acknowledged the problem immediately. Asked what fall prevention measures should be in place for Resident #213, she correctly listed them: fall mats, bed in low position, and the call pad on the right side of the bed because that's where the resident falls.
She confirmed the call pad was neither within reach nor positioned correctly. The care plan interventions designed to prevent future falls weren't being followed.
The resident's fall history made these failures particularly concerning. Four falls in a single month had already established a dangerous pattern. The March 6 fall was followed by another the next day. Two weeks later, the resident fell again on March 19, then once more on March 24.
Each incident should have reinforced the importance of keeping safety equipment properly positioned.
The facility had correctly identified Resident #213 as high-risk for falls. The care plan documented specific interventions: frequent rounding, bilateral fall mats, and crucially, keeping the call pad within reach on the side of the bed where falls typically occurred.
But documentation means nothing if staff don't follow through.
The complaint investigation revealed a gap between written policies and actual practice. While administrators could recite the correct safety measures when questioned, the daily reality was different. Equipment designed to prevent emergencies was routinely misplaced.
For a resident who had already fallen four times, every moment without access to the call pad represented potential danger. Falls among elderly residents can result in serious injuries including hip fractures, head trauma, and other complications that significantly impact quality of life.
The Assistant Director of Nursing's immediate recognition of the problem suggested staff understood the requirements. The repeated misplacement of equipment indicated a failure in consistent implementation rather than lack of knowledge.
When the administrator and Director of Nursing were notified of the findings on October 7 at 2:10 PM, they learned their facility had failed one of nursing home care's most basic safety requirements: keeping emergency equipment where residents can actually use it.
The state's investigation confirmed what the complainant alleged. Fall prevention interventions weren't being properly implemented for a resident with a documented history of multiple falls. The call pad that could summon help during an emergency was consistently placed beyond reach, sitting on medical equipment instead of the bed where care plans required it.
For Resident #213's family, the photograph they took on October 4 captured more than just a misplaced call pad. It documented a system failure that left their loved one vulnerable to preventable harm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westgate Hills Rehab & Healthcare Ctr from 2025-10-09 including all violations, facility responses, and corrective action plans.
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