The resident, identified as R107 in inspection records, scored 5 out of 15 on a cognitive assessment, indicating severe impairment. They required staff assistance with basic mobility and had been diagnosed with muscle wasting and atrophy.
R107's first fall occurred on January 24, when nursing staff found them "on their right side on the floor in front of wheelchair before bedtime." Staff performed range of motion exercises and noted no apparent injuries.
Two days later, the situation escalated dramatically.
On January 26, staff discovered R107 "on the floor with head down" with an abrasion on the right side of their face. The incident report noted the resident "appear more confused than usual" and had "old bruise to left ring finger, and right thigh." Staff described R107 as unable to follow simple directions and "throwing self to the floor, and on the side of the bed several times with difficulty to redirect."
R107 was taking Eliquis, a blood thinner, twice daily. The combination of head trauma and blood-thinning medication prompted staff to contact the on-call provider, who ordered immediate emergency room evaluation and treatment.
When inspectors arrived on January 29, they found R107 back from the hospital, lying in bed with feet hanging off the side. The bed was not in a low position, and while a blanket and sling pad were underneath the resident, no new fall prevention measures had been implemented.
Registered Nurse H confirmed R107 had just returned from the hospital following the fall where they hit their head.
The facility's own policy requires specific action after falls. According to the Fall Management policy, "The licensed nurse will complete... Review and/or revise care plan and link to the resident Kardex." Despite two falls in three days and a hospitalization, R107's fall care plan showed no new interventions added on either January 24 or January 26.
When questioned about fall protocols, Registered Nurse K explained the process to inspectors: "When a resident falls in the facility, they talk about the fall in their interdisciplinary team meeting and decide what should be put in as an intervention." RN K stated the floor nurse bears responsibility for implementing timely interventions after resident falls.
The Director of Nursing confirmed during interview that "timely interventions should be put in after someone falls." The DON acknowledged that floor nurses have guidelines available to implement immediate interventions before the interdisciplinary team meets.
But those guidelines weren't followed.
R107's medical record reveals a pattern of vulnerability that should have triggered heightened vigilance. Admitted to the facility on January 13 with muscle wasting and requiring assistance with bed mobility and transfers, R107 represented exactly the type of high-risk resident for whom prompt fall prevention updates are critical.
The blood thinner medication added another layer of risk. Eliquis increases bleeding complications from head trauma, making R107's second fall particularly dangerous. The emergency room visit confirmed the severity of concerns that should have prompted immediate care plan revisions.
Federal inspectors cited the facility for failing to develop and implement complete care plans that meet residents' needs. The violation affected few residents but represented minimal harm or potential for actual harm.
The inspection occurred as part of a complaint investigation, suggesting someone had raised concerns about care quality at the facility.
R107's case illustrates how administrative failures can compound medical vulnerabilities. A resident already struggling with cognitive impairment, muscle weakness, and medication-related bleeding risks received no additional protection after demonstrating a clear pattern of dangerous falls.
The facility's interdisciplinary team meeting process, while potentially thorough, proved inadequate for addressing urgent safety needs requiring immediate intervention.
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.