Landings of Westerville: NPO Resident Given Liquid - OH
The incident occurred on August 12 at Landings of Westerville Health and Rehab when Licensed Practical Nurse #200 administered chlorhexidine solution to Resident #15, who had explicit nothing-by-mouth orders due to severe medical conditions.
Resident #15 had been at the facility since November 2023 with multiple serious diagnoses including cerebral infarction, emphysema, acute chronic respiratory failure with hypoxia, diabetes, atrial fibrillation and tracheostomy dependence. The resident required total assistance from staff for all activities of daily living and had severe cognitive impairment, scoring just six out of 15 on a standard mental status assessment.
The resident's physician had ordered both a nothing-by-mouth diet and chlorhexidine gluconate solution for oral care. The medication order specified 15 milliliters four times daily, but facility protocols required the antiseptic solution to be applied with foam swabs, not poured into the patient's mouth.
Unit Manager #379 discovered the error two days later when reviewing records. He told inspectors that Nurse #200 had "poured a small amount of chlorhexidine medication in the front of Resident #15's mouth to thoroughly clean her bottom teeth."
The family was immediately notified about "the scant amount of liquid Resident #15 received from her Chlorhexidine administration," according to progress notes dated August 14.
Director of Nursing #393 acknowledged awareness of the incident and conducted emergency training for nursing and respiratory therapy staff the day after the family notification. The training session occurred on August 13, just one day after the violation.
The facility's own training materials clearly outlined proper procedure for oral care with chlorhexidine for nothing-by-mouth patients. The step-by-step instructions specified pouring 10-15 milliliters into a cup, then soaking a foam swab for application. The protocol explicitly warned against double-dipping swabs and required continuous suction during care to prevent aspiration.
For alert patients, the training materials instructed staff to have residents "spit into basin" with "no rinsing with water." The protocols emphasized verifying nothing-by-mouth status and aspiration risk before beginning any oral care.
Nurse #200's method violated multiple safety steps. Instead of using foam swabs, she poured the medication directly into the resident's mouth. The training materials required positioning the patient's head at 30-45 degrees upright or on their side, and maintaining suction equipment during the procedure to prevent the patient from swallowing or aspirating the liquid.
Nothing-by-mouth orders are typically issued for patients at high risk of aspiration, where liquids entering the lungs can cause pneumonia or death. Resident #15's combination of cognitive impairment, respiratory failure, and tracheostomy dependence made proper oral care protocols particularly critical.
The facility identified 17 residents with nothing-by-mouth orders out of its total census of 109 patients. Inspectors found that only Resident #15 was affected by improper liquid administration during oral care.
The violation occurred despite the facility having detailed written protocols and the Director of Nursing's stated awareness of proper procedures for nothing-by-mouth patients. The incident required immediate family notification and emergency staff retraining across multiple departments.
Federal inspectors cited the facility for failing to provide appropriate treatment according to physician orders and resident safety requirements. The violation was classified as causing minimal harm or potential for actual harm.
The August 12 incident highlighted gaps between written protocols and actual nursing practice at the facility. Despite clear instructions requiring foam swab application and continuous suction, the licensed practical nurse chose to pour the antiseptic solution directly into a vulnerable patient's mouth.
Unit Manager #379's discovery of the error through record review, rather than direct observation or reporting by the nurse involved, raised additional questions about supervision and safety monitoring systems at the facility.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 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's physician had ordered both a nothing-by-mouth diet and chlorhexidine gluconate solution for oral care.
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.