The resident, identified as R107, was found lying in bed with their feet hanging off the side when inspectors arrived at Regency at Westland on January 27. The bed wasn't in the low position required for fall prevention. A registered nurse told inspectors the resident had just returned from the hospital after hitting their head in a fall and was now on blood thinners.
R107 had been admitted to the facility on January 13 with muscle wasting and atrophy. Their most recent assessment showed severely impaired cognition, scoring just 5 out of 15 on a standard mental status test. They required staff assistance to move in bed and transfer to chairs.
The falls started three days before the inspection.
On January 24, staff found R107 on their right side on the floor in front of a wheelchair before bedtime. They performed range of motion tests and noted no apparent injuries.
Two days later, on January 26, staff discovered R107 on the floor again, this time with their head down. They had an abrasion on the right side of their face and appeared more confused than usual. Staff noted old bruises on the left ring finger and right thigh. The resident was throwing themselves to the floor and onto the side of the bed repeatedly, unable to follow simple directions.
The on-call provider ordered R107 sent to the emergency room for evaluation and treatment. The resident was already taking Eliquis, a blood thinner, twice daily.
But when inspectors reviewed R107's fall care plan, they found no new fall prevention measures added after either the January 24 fall or the January 26 fall that sent the resident to the hospital.
Registered Nurse K told inspectors that when residents fall, facility staff discuss it in interdisciplinary team meetings and decide what interventions to add. The floor nurse is responsible for putting in timely interventions after falls, she said.
The Director of Nursing confirmed that timely interventions should be implemented after someone falls. Floor nurses have guidelines they can follow to put in interventions immediately, even before the team meeting occurs, the director said.
The facility's own fall management policy requires licensed nurses to "review and/or revise care plan" after incidents.
R107's case illustrates what happens when those policies aren't followed. A resident with severe cognitive impairment and physical limitations fell twice in 72 hours. The second fall was serious enough to cause facial injuries and send them to the emergency room. They returned on blood thinners, which increase bleeding risks from future falls.
Yet their care plan remained unchanged.
The resident's bed wasn't lowered when inspectors found them with their feet dangling off the side. No additional safety equipment had been added. No new monitoring protocols were in place.
The facility's policy existed. The nursing staff knew the requirements. The Director of Nursing confirmed the procedures.
But R107 returned from the hospital to the same conditions that had failed to prevent two falls in three days.
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.