The resident, identified as R107 in inspection documents, was found on the floor in front of their wheelchair on January 24. Two days later, staff discovered them on the floor again with their head down and an abrasion on the right side of their face.
R107 appeared more confused than usual after the second fall. They threw themselves to the floor and onto the side of the bed several times, with staff unable to redirect them. The resident was taking Eliquis, a blood thinner, twice daily.
Staff called the on-call provider after the second fall and received orders to send R107 to the emergency room for evaluation and treatment.
When inspectors arrived at Regency at Westland on January 27, they found R107 had just returned from the hospital. The resident was lying in bed with their feet hanging off the side. Their bed was not in the low position required for fall prevention, and a blanket and sling pad were underneath them.
Registered Nurse H told inspectors R107 had hit their head during the fall and was on blood thinners.
The facility's own records showed R107 had been admitted on January 13 with muscle wasting and atrophy. A mental status assessment scored them 5 out of 15, indicating severely impaired cognition. The resident required staff assistance with bed mobility and transfers.
Despite two falls in three days and a hospitalization, inspectors found no new fall prevention interventions added to R107's care plan on January 24 or January 26.
Registered Nurse K explained the facility's process during an interview with inspectors. When a resident falls, staff discuss it in their interdisciplinary team meeting and decide what interventions to implement. The floor nurse is responsible for adding timely interventions after a fall.
The Director of Nursing confirmed that timely interventions should be implemented after falls. Floor nurses have guidelines they can follow to put interventions in place until the team meeting occurs, the director said.
The facility's own Fall Management policy requires licensed nurses to "review and/or revise care plan and link to the resident Kardex" after falls.
R107's case illustrates the human consequences when facilities fail to follow their own safety protocols. The resident's cognitive impairment made them particularly vulnerable to injury from falls. Their BIMS score of 5 out of 15 indicated they could not reliably understand or remember safety instructions.
The blood thinner medication increased the risk of serious bleeding from head injuries. When R107 fell the second time and hit their head, the combination of cognitive impairment and anticoagulation therapy made immediate medical evaluation essential.
Staff documented that R107 had "old bruise to L ring finger, and R thigh" in addition to the fresh facial abrasion from the January 26 fall. The resident's inability to follow simple directions and tendency to throw themselves to the floor suggested their condition was deteriorating.
The facility's failure to implement fall prevention measures after the first incident on January 24 meant R107 remained at high risk. When the second fall occurred two days later, it resulted in head trauma serious enough to require emergency room treatment.
Federal regulations require nursing homes to develop and implement complete care plans that meet all residents' needs. These plans must include specific interventions with measurable actions and timetables.
For residents like R107, who have multiple risk factors including cognitive impairment, mobility limitations, and blood thinner medications, timely fall prevention interventions can mean the difference between a minor incident and a life-threatening injury.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Regency At Westland from 2026-01-29 including all violations, facility responses, and corrective action plans.