The resident, identified as R148 in inspection records, told federal investigators that staff at Regency at Westland sometimes forgot to provide basic colostomy care. When reminded, they would empty or change the bag, but the oversight created a pattern of neglect for someone who couldn't perform the task independently.
R148 was admitted to the facility on January 24 with colostomy status and diverticulitis. The resident scored 11 out of 15 on a cognitive assessment, indicating impaired mental function, and required staff assistance with basic movements like getting out of bed and transferring to chairs.
Despite these clear care needs, the facility failed to establish proper protocols.
When inspectors reviewed R148's medical records, they found no physician's orders for colostomy care. The Treatment Administration Record, which should document all care provided, contained no entries about colostomy maintenance. Five days after admission, the resident was left to remind staff when the medical device needed attention.
The oversight represents a fundamental breakdown in admission procedures. Unit Manager V told inspectors that admitting nurses should enter orders for devices like colostomies when new residents arrive. The manager acknowledged conducting chart audits to catch missing orders, but this system failed R148.
Director of Nursing couldn't explain the gap. When questioned about why colostomy care orders weren't entered on admission, the nursing director stated uncertainty about the cause. The director noted that unit managers perform chart audits and double-check orders after new admissions, yet R148's essential care requirements slipped through multiple review points.
The facility's own policies provided no guidance. Inspectors found that Regency at Westland's colostomy policy failed to address actual colostomy care procedures, leaving staff without clear protocols for this medical necessity.
R148's experience illustrates the human impact of these systemic failures. Living with a colostomy requires regular emptying and cleaning to prevent infection, skin breakdown, and the psychological distress of accidents. When staff forget these tasks, residents face physical discomfort and the indignity of having to advocate for basic medical care.
The resident's report that the bag nearly burst reveals how severe the neglect became. Colostomy bags have capacity limits, and overfilling risks spillage that can cause skin irritation, infection, and embarrassment. That staff expressed surprise at the bag's fullness suggests they weren't monitoring it appropriately.
Federal regulations require nursing homes to provide necessary medical services, including ostomy care for residents who need it. The citation found the facility failed this standard for R148, though inspectors noted the violation caused minimal harm or potential for actual harm.
The case raises questions about care coordination at Regency at Westland. Multiple staff members and managers are involved in admission processes, chart reviews, and daily care delivery. Yet none ensured that a resident with an obvious medical device received appropriate attention.
R148's cognitive impairment made the oversight particularly concerning. The resident couldn't independently manage colostomy care and had to rely on memory and communication skills that were already compromised. When staff forgot their responsibilities, R148 bore the consequences.
The inspection occurred after a complaint was filed about the facility's care practices. Federal investigators spent time observing operations and interviewing staff, ultimately documenting the colostomy care failure as part of their findings.
For R148, the violation meant living with uncertainty about when essential medical care would be provided. The resident learned to speak up when the colostomy bag needed attention, taking on a burden that should have been the facility's responsibility from the moment of admission.
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.