Westover Retirement Community failed to follow through on the July referral for the 79-year-old woman, who suffers from diabetic neuropathy that causes heaviness and numbness in her left foot and leg. She has trouble lifting her leg and foot.
Nurse Practitioner #105 referred the resident to neurology on July 22 after examining her worsening symptoms. The referral was documented in both the provider's progress note and a nursing note written at 5:52 that morning, which stated the resident had been "made aware of the referral."
Six days later, on July 28, the same nurse practitioner noted in another progress report that the resident "had previously been referred to neurology for left leg and foot heaviness and numbness." But no documentation exists showing the resident ever saw a neurologist.
The resident, identified as #43 in the inspection report, was admitted to the facility in February with type II diabetes mellitus with polyneuropathy and generalized anxiety. Diabetic polyneuropathy can cause permanent nerve damage if left untreated, leading to increased pain, loss of sensation, and mobility problems.
When federal inspectors asked about the referral during their November 25 visit, the Director of Nursing said she was "unsure if Resident #43 was seen by a neurologist following the referral written by NP #105 on July 22."
The nurse practitioner who wrote the original referral also couldn't provide answers. During an interview at 1:58 that afternoon, NP #105 confirmed she had referred the resident to neurology in July for the polyneuropathy symptoms but "was unable to verify if Resident #43 had been seen by a neurologist."
The breakdown represents a failure in the facility's system for tracking specialist referrals. Federal regulations require nursing homes to provide appropriate treatment according to physician orders and residents' medical needs.
For four months, the resident's neurological symptoms went without specialized evaluation. The inspection report notes she continued experiencing left foot and leg heaviness, numbness, and difficulty with mobility — the exact symptoms that prompted the July referral.
Westover Retirement Community houses 51 residents. Inspectors reviewed physician orders for referral services for four residents total and found this tracking failure affected one of them.
The violation was investigated as part of two complaint cases filed against the facility. Federal inspectors classified the harm level as "minimal harm or potential for actual harm," though the long-term effects of untreated diabetic neuropathy can be severe.
The resident remains at the facility. Her medical record shows no evidence she ever received the neurological care ordered by her provider five months ago.
Nobody at Westover could explain what happened to the referral or why the resident never saw a specialist for her progressive nerve damage.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westover Retirement Community from 2025-11-25 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Westover Retirement Community
- Browse all OH nursing home inspections