Resident #105 lived with severe cognitive impairment, epilepsy, heart failure, intellectual disability, and muscle weakness. Her care plan, last revised in October 2023, specifically called for floor mats next to her bed and a scoop mattress with raised edges to prevent falls.
The interventions were put in place after a fall in March 2024. But when inspectors arrived at Medilodge of Westwood in late October, they found none of the required equipment.
Over four separate observations on October 29 and 30, inspectors found the same thing: no fall mats anywhere in Resident #105's room, and a regular mattress instead of the prescribed scoop design.
At 11:04 AM on October 29, she lay in bed with her eyes closed. No mats. At 3:10 PM, still in bed. No mats. Again at 3:40 PM. The next morning at 8:21 AM, inspectors found her in her wheelchair in the hallway just outside her room. Still no mats visible anywhere.
A certified nursing assistant told inspectors on October 30 that Resident #105 previously had fall mats placed along the sides of her bed when she was sleeping. The aide said she didn't know where the mats were now and couldn't recall ever seeing a scoop mattress in use for the resident.
The Director of Nursing later explained that staff had decided Resident #105 no longer needed the fall prevention equipment and removed it. But the care plan still required both interventions, creating a dangerous disconnect between what the facility's official protocols demanded and what staff were actually doing.
Care plans serve as the roadmap for resident safety and must be updated whenever a resident's condition or needs change. Federal regulations require facilities to review and revise these plans quarterly at minimum, and immediately when circumstances change.
Resident #105's multiple medical conditions made fall prevention particularly critical. Her epilepsy could cause seizures that might result in falls. Her intellectual disability and severe dementia affected her ability to recognize dangers. Heart failure and muscle weakness further compromised her stability and mobility.
The facility's own assessment from September showed she had severe cognitive impairment, though it noted no recent fall history since her previous evaluation.
The nursing director acknowledged that care plans should be reviewed and updated quarterly and whenever changes occur. She said the decision to remove the fall prevention equipment was made because Resident #105 no longer required those specific interventions.
But the care plan remained unchanged for over a year after the equipment disappeared. Any staff member consulting Resident #105's official care plan would expect to find floor mats beside her bed and a specialized mattress designed to prevent falls.
The outdated plan created potential for confusion among caregivers about what safety measures were actually in place. New staff or those unfamiliar with the resident might assume the prescribed equipment was being used, while others knew it had been removed without documentation.
This type of documentation failure can have serious consequences. Care plans guide not just daily caregiving but also emergency responses. If Resident #105 experienced a fall, emergency responders and medical staff would rely on her care plan to understand what preventive measures should have been in place.
The inspection found that the facility failed to maintain accurate care planning for residents with complex medical needs requiring specialized safety interventions.
Resident #105's case illustrates how administrative oversights can undermine resident safety even when clinical decisions may be appropriate. Whether or not she still needed the fall prevention equipment, her care plan should have reflected the actual care being provided.
The facility's failure to update the documentation meant that for more than a year, Resident #105's official care plan bore no resemblance to her actual living situation. Staff had made a clinical decision to remove safety equipment but never formalized that change in the documents that guide her daily care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Medilodge of Westwood from 2025-11-24 including all violations, facility responses, and corrective action plans.