F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
Based on medical record review, staff interviews, and facility policy review, the facility failed to honor
Resident #15 ‘s right to have a camera surveillance in her room when her camera was unplugged and not
reconnected to power. This affected one resident (Resident #15) out of 15 residents identified by the facility
as having surveillance cameras in their rooms. Facility census was 109. Findings include: Review of
Resident #15's medical record revealed an admission date of 11/27/2023 with diagnoses that included but
were not limited to cerebral infarction, emphysema, acute chronic respiratory failure with hypoxia, diabetes
mellitus, atrial fibrillation and depression.Review of Resident # 15's most recent Minimum Data Set (MDS)
3.0 assessment dated , 07/25/25 revealed a Brief Interview for Mental Status (BIMS) score of six indicating
the resident was cognitively impaired. The resident was assessed to require total assistance from staff with
activities of daily living.Review of Resident # 15's progress notes dated 08/05/25 revealed that Unit
Manager (UM) # 379 removed a power strip from the resident's room.Interview on 09/02/25 at 1:35 P.M.
with UM # 379 revealed on 08/05/25 he removed a power strip from Resident #15's room that was attached
to her surveillance camera. UM # 379 confirmed he did not plug the camera to a power source after he
removed the power strip. UM #379 stated the camera was not plugged in by any staff member, and family
was notified and he was unsure when family came to the facility to reconnect the camera.Interview on
09/02/25 at 4:05 P.M. with the Administrator revealed she was unaware the surveillance camera in Resident
#15's room was not reconnected to power after the power strip was removed by the facility staff.Review of
facility policy titled Electronic Monitoring in Resident Rooms dated March 23, 2022 revealed: The Facility
will permit residents and legally authorized people to install and use electronic monitoring devices in
accordance wit applicable laws. Only authorized facility personnel are permitted to install electronic
monitoring devices in resident rooms.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
366494
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366494
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/02/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Landings of Westerville Health and Rehab The
350 County Line Road West
Westerville, OH 43082
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on medical record review, review of facility training, and staff interviews, the facility failed to ensure
that residents with Nothing by Mouth (NPO) orders did not receive any liquids by mouth during oral care.
This affected one (Resident #15) out of 17 residents the facility identified as NPO. The facility census was
109.Findings include:Review of Resident #15's medical record revealed an admission date of 11/27/2023
with diagnoses that included but were not limited to cerebral infarction, emphysema, acute chronic
respiratory failure with hypoxia, diabetes mellitus, atrial fibrillation, tracheostomy dependent and
depression.Review of Resident # 15's most recent Minimum Data Set (MDS) 3.0 assessment dated ,
07/25/25 revealed a Brief Interview for Mental Status (BIMS) score of six indicating the resident was
cognitively impaired. The resident was assessed to require total assistance from staff with activities of daily
living and oral hygiene care.Review of Resident #15's progress notes dated 08/14/25 by Unit Manager
(UM) # 379 revealed family was contacted regarding the scant amount of liquid Resident #15 received from
her Chlorhexidine (antimicrobial) administration on 8/12/25.Review of Resident # 15's current monthly
physicians orders dated 08/25/25, revealed an NPO diet order and an order for Chlorhexidine Gluconate
Solution (medication used for oral care with NPO residents) 0.12%; give 15 milliliters (ml) orally four times a
day.Review of Resident #15's August 2025 Medication Administration Record (MAR) revealed Licensed
Practical Nurse (LPN) # 200 signed as administering Chlorhexidine Gluconate Solution on 08/12/25 at 9:00
P.M. Interview on 09/02/25 at 1:35 P.M. with UM # 379 revealed that Nurse #200 poured a small amount of
chlorhexidine medication in the front of Resident #15's mouth to thoroughly clean her bottom teeth. He also
stated that Director of Nursing (DON) #393 was aware and had educated the staff on oral care for NPO
residents. Interview on 09/02/25 at 2:25 P.M. with DON #393 revealed he was aware of the incident and had
educated nursing and respiratory therapy staff on oral care with chlorhexidine for NPO patients on
08/13/25.Review of facility training titled Oral Care with Chlorhexidine -NPO patients undated revealed the
following step by step instructions: 1. Verify & prepare: Confirm order, allergies, NPO status, aspiration risk.
Wash hands and apply gloves. 2. Position: head of bed (HOB) 30-45 upright OR side-lying if unable. 3.
Application: Pour 10-15 ml into a cup, soak foam swab (no double dipping). 4. Cleaning: Swab inner cheeks,
gums, tongue, teeth - replace swab if soiled. 5. Suction: Yankauer/inline suction during care. If alert, spit into
basin (no rinsing with water). 6. Completion: Dispose of supplies, remove personal protective equipment
(PPE), document care and findings.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366494
If continuation sheet
Page 2 of 2