Federal inspectors found the 83-bed facility failed to implement timely care plan changes after the resident's falls on January 24 and January 26, despite facility policy requiring nurses to revise fall prevention measures immediately.
The resident, identified as R107 in inspection records, was admitted January 13 with muscle wasting and atrophy. A cognitive assessment revealed severe impairment, scoring just 5 out of 15 points on a standard mental status exam. The person required staff help moving in bed and transferring to chairs.
On January 24, staff found R107 on the floor next to a wheelchair before bedtime. Nurses performed range of motion tests and noted no apparent injuries. Two days later, staff discovered R107 on the floor again, this time with their head down and an abrasion on the right side of their face.
The incident report described R107 as "more confused than usual" with old bruises on the left ring finger and right thigh. The resident was "unable to follow simple directions" and kept "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 prescribed at 5 milligrams twice daily. After the second fall, an on-call provider ordered emergency room evaluation and treatment.
When inspectors arrived January 27, 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 no fall prevention equipment was visible beneath the resident.
Registered Nurse H confirmed R107 had just returned from the hospital after hitting their head during the fall.
Despite two documented falls in three days, including one requiring hospitalization, facility records showed no new fall prevention interventions added to R107's care plan on either January 24 or January 26.
Registered Nurse K told inspectors that after any fall, staff discuss the incident in interdisciplinary team meetings to determine appropriate interventions. The floor nurse bears responsibility for implementing timely interventions, RN K explained.
The Director of Nursing confirmed that timely interventions should follow any fall. Floor nurses have guidelines they can follow to implement immediate measures before the team meeting occurs, the DON said.
Facility policy on fall management states clearly that licensed nurses must "review and/or revise care plan" after any fall incident.
The inspection revealed a gap between written policy and actual practice. While the facility had procedures requiring immediate care plan updates after falls, staff failed to follow them for a vulnerable resident who fell twice in rapid succession.
R107's case illustrates the particular risks facing cognitively impaired nursing home residents. With a BIMS score indicating severe cognitive decline, R107 could not understand or follow safety instructions. The person's muscle wasting condition likely contributed to mobility problems and fall risk.
The combination of cognitive impairment, physical weakness, and blood thinner medication created a dangerous situation requiring heightened fall prevention measures. Instead, R107 experienced two falls without any documented changes to prevent future incidents.
Federal inspectors classified this as a minimal harm violation affecting few residents. However, for R107, the consequences included head trauma, emergency room treatment, and continued exposure to fall risks upon return to the facility.
The inspection occurred during R107's readmission period, when the resident remained at high risk for additional falls. Inspectors observed safety equipment was still not in place, suggesting ongoing problems with fall prevention implementation.
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.