The January 29 inspection at Regency at Westland found the facility failed to provide proper colostomy care for resident R148, who had been admitted five days earlier with a colostomy and diverticulitis diagnosis.
R148 was observed lying in bed with a colostomy located in their left lower abdomen. The resident explained that staff sometimes forgot to empty the bag, but would do so if reminded. "One time their colostomy bag was so full, staff had to take two trips to empty it and were surprised their colostomy bag did not burst," inspectors documented.
The resident had been admitted on January 24 with documented medical conditions including colostomy status and diverticulitis of large intestines. A cognitive assessment revealed impaired mental function, with R148 scoring 11 out of 15 on a brief interview test. The resident also required staff assistance with bed mobility and transfers.
Despite these clear care needs, inspectors found no physician's orders related to colostomy care in R148's medical record. The facility's Treatment Administration Record also contained no documentation of any colostomy care being provided during the five-day stay.
Unit Manager V told inspectors that when new residents are admitted, "the admitting nurse should put in the orders for things like a colostomy." The manager explained that unit managers complete chart audits and "will clean up orders or add missing orders."
But no such orders had been entered for R148.
Director of Nursing stated they were "unsure why the colostomy care orders were not entered on admission." The nursing director said unit managers conduct chart audits and "double check the orders after new admissions."
The facility's own policy on colostomy care provided no guidance on the issue, with inspectors noting it "did not address colostomy care."
Colostomy bags collect waste from the large intestine through an opening in the abdomen. Regular emptying prevents the bag from becoming overfull, which can cause leakage, skin irritation, or bag rupture. Residents with cognitive impairment may not consistently recognize when the bag needs attention or may forget to request help.
The oversight left R148 dependent on remembering to ask for help with a medical device that requires routine professional monitoring. For someone with documented cognitive impairment who needed assistance with basic mobility, this represented a significant gap in care.
The inspection occurred as part of a complaint investigation. Federal regulators classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents.
The case illustrates how admission procedures can fail residents with complex medical needs. R148 arrived with clearly documented conditions requiring specialized care, yet the facility's systems failed to translate those diagnoses into actual care orders.
Unit Manager V's explanation that admitting nurses "should" enter such orders suggests the facility relies on individual staff members to remember complex care requirements rather than systematic protocols. The manager's statement about cleaning up missing orders after the fact indicates this isn't an isolated problem.
The Director of Nursing's uncertainty about why the orders weren't entered points to a breakdown in the admission process that the facility's leadership couldn't explain even after it had been identified.
R148's experience of having to remind staff about colostomy care transforms a routine medical procedure into a resident's responsibility. The incident where the bag became so full it nearly burst demonstrates the consequences when that system fails.
The resident remains at Regency at Westland, still requiring colostomy care that the facility had not properly ordered or documented as of the inspection date.
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.