Landings of Westerville: NPO Resident Given Liquid - OH
The resident, identified in the report as Resident 15, had lived at the facility since November 2023. Her medical history included a cerebral infarction, emphysema, acute and chronic respiratory failure with low oxygen levels, diabetes, atrial fibrillation, and depression. She breathed through a tracheostomy and required total staff assistance for daily care, including oral hygiene. A cognitive assessment from July 2025 placed her BIMS score at six, indicating significant cognitive impairment. She could not manage her own care or advocate for herself if something went wrong.
Her physician had ordered her to receive nothing by mouth. The same order included a specific protocol for oral care: chlorhexidine gluconate solution, 0.12 percent, applied four times daily using foam swabs, with suction used throughout to prevent any liquid from being swallowed or aspirated.
On the night of August 12, 2025, Licensed Practical Nurse 200 signed the medication administration record indicating she had given the chlorhexidine dose at 9:00 p.m. What the record did not capture was how she gave it.
Two days later, on August 14, the unit manager documented in a progress note that the resident's family had been contacted about the incident, describing the amount of liquid the resident received as "scant."
When inspectors interviewed the unit manager on September 2, he described what happened: the nurse had poured a small amount of the chlorhexidine solution directly into the front of the resident's mouth to clean her bottom teeth. He confirmed that the Director of Nursing had been made aware and had since educated staff on the proper oral care procedure for NPO residents.
The Director of Nursing, interviewed the same afternoon, confirmed he knew about the incident and said he had held a training session on August 13, the day after it happened, covering nursing and respiratory therapy staff.
That training document, reviewed by inspectors, was undated. It laid out a six-step process: confirm the order and the resident's NPO and aspiration risk status, position the resident at a 30 to 45 degree angle or on their side, soak a foam swab in 10 to 15 milliliters of solution without double-dipping, swab the inner cheeks, gums, tongue, and teeth, use suction continuously throughout, and document the care. The instructions were specific. They existed before August 12.
The nurse had poured the solution directly into the mouth instead.
For a resident breathing through a tracheostomy, with documented respiratory failure and an aspiration risk, the difference between a soaked swab with active suction and liquid poured into the mouth is not a minor procedural distinction. Aspiration, the entry of liquid into the airway, is a serious and recognized risk for patients in exactly this condition. The NPO order and the chlorhexidine protocol together existed to manage that risk.
Inspectors identified the violation as affecting one resident out of 17 at the facility who were on NPO orders. The facility census at the time of the inspection was 109.
The family learned about it from a progress note two days after it happened. The staff learned about the correct procedure the morning after. The training document describing that procedure had no date on it, leaving unclear when it was written or whether it had ever been reviewed before the incident occurred.
Resident 15 remained at the facility, tracheostomy dependent, requiring total care, unable to speak for herself about what happened on the night of August 12.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Landings of Westerville Health and Rehab The from 2025-09-02 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
LANDINGS OF WESTERVILLE HEALTH AND REHAB THE in WESTERVILLE, OH was cited for violations during a health inspection on September 2, 2025.
The resident, identified in the report as Resident 15, had lived at the facility since November 2023.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.