Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westerville Post Acute. during CMS and state inspections, most recent first.
Call Light Out of Reach: A resident with severe cognitive impairment, wheelchair dependence, and extensive medical diagnoses had her call light wrapped around the bed rail and out of reach while she was seated in her wheelchair. The resident said she was looking for the call light and did not know where it was until she saw it on the bed rail, and an RN verified it was not within reach. The care plan called for the call light to be accessible when in the room, and facility policy stated staff are to ensure proper response to call lights.
Dietary preferences were not honored for two residents. One resident with moderate cognitive impairment and severe malnutrition had no likes, dislikes, or preferences documented on the dietary interview or meal tickets, despite stating she had shared them at admission and still received foods she did not like. Another resident with COPD, DM2, and depression also had no preferences documented, reported that chicken was still served despite her dislike of it, and said she was not interviewed by a dietitian at admission. The DON and Dietary Director verified the missing documentation, and the facility policy required resident food preferences to be assessed and considered.
Infection Control Lapse During Incontinence Care: A CNA failed to follow hand hygiene and glove-use procedures during incontinent care for a resident who was dependent on staff for toileting hygiene. The CNA put on gloves while gathering supplies, kept them on while preparing and providing care, and did not remove them until after the care was completed; the facility policy required hand hygiene immediately before touching a resident and handwashing before putting on gloves.
A resident discharged home with multiple chronic conditions, including CVA, HTN, atrial fibrillation, and kidney cancer, did not have an adequate medication supply after leaving the facility. Although the discharge summary listed follow-up care and the resident was sent with medications and education, the facility did not call the prescriptions into the pharmacy at discharge; the NP did so several days later, and only one day of meds had been provided initially.
Failure to Offer Resident-Centered Activities: A cognitively intact resident with a history of cerebral infarction and depression had documented interests in books, music, group activities, news, religious services, and favorite activities, with a preference for in-room activities. Although the care plan included music, one-on-one visits, activity materials, and room visits, there were no documented activity offers or provided activities, and the Activity Director confirmed there was no evidence of one-on-one or group activity logs.
A resident with DM received lispro after a CGM displayed HI, but an LPN did not obtain a manual BG reading when requested and did not notify the provider before giving insulin. The MAR later showed a BG of 388 mg/dL, and the DON confirmed the provider had not been notified; after surveyor intervention, a manual check showed 491 mg/dL and additional insulin was ordered. Facility policy required notifying the provider of discrepancies before insulin administration.
Undated opened bulk medications were found on the 400 hall med cart, including Milk of Magnesia, Tylenol 325 mg and 500 mg, Active Liquid Protein, Geri-Tussin, and Alkums antacid tablets. An LPN confirmed that opened bulk medication bottles should be dated with the open date and verified the listed items were not dated.
A resident with multiple wounds did not receive or have documented physician-ordered dressing changes for two consecutive days. The TAR and progress notes lacked evidence of completion or refusal, and the resident reported that wound care was not offered during night shifts. Interviews with the DON and an LPN confirmed that required documentation and care were not provided according to facility policy.
Surveyors found that the facility did not complete required fall investigations or root cause analyses after a resident's fall, failed to document or implement physician-ordered safety interventions such as protective headgear for a resident with neurological risk, and did not ensure fall prevention measures like low beds and fall mats were in place for another resident. Staff confirmed that care plans and orders lacked necessary details, and prescribed interventions were not consistently followed.
A resident with diabetes and multiple comorbidities did not consistently receive insulin as ordered, with several doses of long-acting insulin administered outside the prescribed bedtime window and one dose missed entirely. Staff interviews and MAR review confirmed delays, omissions, and inaccurate documentation of insulin administration, despite facility policy requiring timely medication delivery.
Staff failed to use required PPE, including gowns and gloves, while providing high-contact skin care to a resident with multiple medical conditions and a feeding tube, despite physician orders, posted signage, and facility policy mandating enhanced barrier precautions. Staff incorrectly believed the precautions did not apply, and the DON confirmed the oversight.
Call Light Out of Reach
Penalty
Summary
The facility failed to ensure the call light was within reach for one resident, Resident #640, who was observed in a wheelchair with the call light wrapped around the top rail of the bed and out of reach. Resident #640 had an admission date of 01/24/22 and diagnoses including atherosclerotic heart disease, COPD, hyperlipidemia, morbid obesity, hypertension, major depressive disorder, Alzheimer's disease with late onset, dementia, chronic respiratory failure, and anxiety disorder. The quarterly MDS assessment documented a BIMS score of 7, indicating severe cognitive impairment, and showed the resident was dependent on a wheelchair for mobility and required maximal to dependent assistance with ADLs. The care plan for Resident #640 identified fall risk related to impaired mobility and medication use and included the intervention that the call light be accessible when in the room. During observation, the resident stated she was looking for her call light and did not know where it was until she looked on the bed rail. RN #220 verified that the call light was wrapped around the bed rail and out of the resident's reach. CNA #485 stated that Resident #640 does use her call light. The facility policy on call light response stated that call lights are a method of notification for those in need of assistance and that all employees are to ensure proper response time and service to call lights initiated.
Dietary Preferences Not Honored for Two Residents
Penalty
Summary
The facility failed to ensure dietary preferences were honored for two residents, #605 and #630, out of five residents reviewed for food preferences. The deficiency was identified through interview, record review, and facility policy review, and involved meal tickets and dietary interviews that did not reflect resident likes, dislikes, or preferences. The facility census was 89. Resident #605 was admitted with diagnoses including hydronephrosis with renal and ureteral calculous obstruction, severe protein-calorie malnutrition, a stage 3 pressure ulcer to the left buttock, diastolic heart failure, adult failure to thrive, hypertension, spastic hemiplegia affecting the left nondominant side, cognitive communication deficit, and obstructive reflux uropathy. The admission MDS showed a BIMS of 12, indicating moderate cognitive impairment, and the resident was dependent for all ADLs and required supervision for eating. The care plan included honoring food preferences, but the dietary interview had no preferences, likes, or dislikes checked, and meal tickets for breakfast, lunch, and dinner also had no dislikes listed. The resident stated she did not like much of the food, had told staff her likes and dislikes on admission, received items she did not like, and did not know about the always available menu until the Dietary Manager came to ask about preferences. Resident #630 was admitted with diagnoses including COPD, muscle weakness, type 2 diabetes, acute and chronic respiratory failure, hypertension, and major depressive disorder. The quarterly MDS showed a BIMS of 15 and that the resident required set up for meals. The care plan stated food preferences were to be based on resident choice, but the dietary interview had no preferences, likes, or dislikes checked, and meal tickets for breakfast, lunch, and dinner had no dislikes listed. The resident stated the food was terrible, said she had noted that she did not like chicken but still received it, and reported that no dietitian interviewed her at admission. The facility policy stated residents are to receive a nourishing, palatable, well-balanced diet that takes into consideration each resident's preferences, and that staff are to assess likes, dislikes, and eating habits.
Infection Control Lapse During Incontinence Care
Penalty
Summary
The facility failed to follow infection control procedures during incontinence care for one resident. Resident #630 was admitted on 09/24/25 with diagnoses including chronic obstructive pulmonary disease, muscle weakness, type 2 diabetes, acute and chronic respiratory failure, hypertension, and major depressive disorder. The quarterly MDS assessment showed a BIMS score of 15, indicating no cognitive impairment, and the resident was dependent on staff for toileting hygiene. The care plan identified bowel and bladder incontinence related to limited mobility, medication use, and overactive bladder, with interventions to provide check-and-change incontinence management and observe for signs and symptoms of urinary tract infection. During observation of incontinent care, a CNA washed her hands and put on gloves, then carried two wash basins into the room, set them on a bedside table, and prepared the resident for care. The CNA kept the gloves on while gathering supplies and did not remove them until after performing incontinent care. Afterward, the CNA placed trash and wash clothes into separate bags and took the wash basins to the bathroom to empty them, removing her gloves and washing her hands only after leaving the resident area. The facility's Hand Hygiene policy stated hand hygiene is indicated immediately before touching a resident, and the Perineal Care policy included washing and drying hands thoroughly before putting on gloves.
Inadequate Discharge Medication Planning
Penalty
Summary
The facility failed to ensure an adequate post-discharge medication plan for a former resident who was discharged home from the facility. The resident had diagnoses including cerebral infarction, hypertension, malignant neoplasm of kidney, and atrial fibrillation, and an MDS assessment documented a BIMS score of 15, indicating intact cognition. The discharge summary, initiated before discharge, listed the resident’s primary care appointment, pharmacy, home health company, and durable medical equipment company, and noted that the resident was given a copy of current medications and when they were last received. Progress notes also stated that medications were sent with the resident and that the resident was educated on upcoming appointments and the medication schedule. Despite this, the resident did not have important medications for several days after discharge because the facility did not ensure the medications were called into the pharmacy at discharge. The resident’s discharge medication list included amlodipine, atorvastatin, darbepoetin alfa, melatonin, midodrine, mirtazapine, pantoprazole, torsemide, warfarin sodium, metoprolol tartrate, and Renvela. A family member reported that the resident lacked medications needed for his health conditions for several days after leaving the facility. The pharmacist stated that the nurse practitioner called the medications into the pharmacy four days after discharge, and the DON confirmed that only one day of medication had been provided because the facility pharmacy delivered only one day in advance and the nurse practitioner was responsible for ordering the medications upon discharge.
Failure to Offer Resident-Centered Activities
Penalty
Summary
The facility failed to offer activities of interest to a resident whose medical record showed a history of cerebral infarction and depression. The resident’s MDS 3.0 comprehensive assessment indicated a BIMS score of 15, showing cognitively intact status, and documented that books, newspapers, magazines, music, group activities, news, religious services or practices, and favorite activities were somewhat important to him. His activity assessment also identified fishing and skiing as interests and noted a preference for in-room activities. The care plan identified a need for activities consistent with the resident’s abilities and interests, including music and one-on-one visits, with interventions to assist with activities, encourage attendance, provide activity materials, and provide room visits for socialization. However, review of activity logs showed no documented one-on-one visits and no group activities, and the medical record contained no documentation that activities were offered or provided. The Activity Director confirmed there was no evidence that activities were offered and no activity logs were available for the resident for either one-on-one visits or group activities.
Failure to Notify Provider for High Blood Glucose Before Insulin Administration
Penalty
Summary
The facility failed to ensure a resident was free from a significant medication error when the physician was not notified of a high blood glucose reading before insulin was administered. Resident #25 was admitted with diagnoses including diabetes type one, hypertension, and chronic obstructive pulmonary disease, and required staff assistance with toileting, dressing, and mobility. Physician orders included insulin glargine 15 units daily, insulin lispro 8 units three times daily with sliding scale, and a sliding scale order that required notification of the MD when blood sugar was above 400 mg/dL. There were no orders for a continuous glucose monitor. During insulin administration, an LPN checked the resident’s continuous glucose monitor, which displayed HI with no numeric value, and then drew up and administered 13 units of lispro without obtaining a manual blood glucose reading after the resident requested one. The LPN confirmed she did not take a manual glucose reading and did not contact the physician, stating she would re-check the glucose in about 30 minutes. The MAR later documented a blood glucose of 388 mg/dL. The DON confirmed the physician was not notified, and after surveyor intervention the DON notified the NP and the LPN obtained a manual reading of 491 mg/dL, after which additional insulin was ordered. Facility policy stated the nurse will notify the provider of any discrepancies prior to administering insulin and must document the resident’s blood glucose result as ordered.
Undated Opened Bulk Medications on Medication Cart
Penalty
Summary
The facility failed to ensure that opened bulk medications were properly labeled with an open date or discard date. During observation of the 400 hall nurses cart, opened and undated bulk medications were found, including a half-empty bottle of Milk of Magnesia 473 ml, a half-empty bottle of Tylenol 325 mg 100 count, a half-empty bottle of Tylenol 500 mg 100 count, a half-empty bottle of Active Liquid Protein 887 ml, a half-empty bottle of Geri-Tussin 473 ml, and a half-empty bottle of Alkums antacid tablets 150 count. The LPN interviewed at the time stated that opened bulk medication bottles should be dated with the open date and verified that the listed medications were not dated.
Failure to Complete and Document Physician-Ordered Wound Care
Penalty
Summary
The facility failed to ensure that dressing changes for a resident with multiple wounds were completed as ordered by the physician. The resident, who had diagnoses including mild cognitive impairment, diabetes, paraplegia, chronic kidney disease, and both an unstageable pressure injury and a deep tissue injury, had specific physician orders for wound care to the left heel and right buttock. These orders required dressing changes every shift and as needed. Review of the Treatment Administration Record (TAR) and progress notes for two consecutive days showed no documentation that the dressing changes were completed or refused. The resident reported that wound care was not offered or provided during night shifts on those dates, and there was no evidence of refusal. Interviews with the DON and the LPN assigned to the resident confirmed that if treatments were completed or refused, they should have been documented on the TAR, with refusals also requiring a progress note and notification to the wound nurse and physician. The facility's policy required detailed documentation of dressing changes, including date, time, type of care provided, and any refusals. The lack of documentation and failure to provide or record the required wound care constituted non-compliance with physician orders and facility policy.
Failure to Investigate Falls and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure a complete investigation and root cause analysis was conducted after a resident sustained a fall, and did not implement fall safety interventions as outlined in residents' care plans. For one resident with severe cognitive impairment and a history of behaviors such as rejection of care, there was no evidence of a completed post-fall investigation or review after the resident reported a fall that resulted in an inability to move his right leg and required hospital transfer. Additionally, the resident's annual fall risk assessment was found to be incomplete. Another resident with multiple complex diagnoses, including chronic respiratory failure and hemiplegia, was observed without required protective headgear while in bed, despite hospital discharge instructions indicating helmet use during transfers and when out of bed. There was no documentation in the care plan or physician orders specifying the need, frequency, or rationale for the head protection, and staff confirmed that this information was only added after surveyors requested clarification. Prior to this, there was no system in place to ensure consistent staff guidance regarding the use of head protection for this resident. A third resident, who was alert and oriented with diagnoses including diabetes and paraplegia, had care plan interventions for a low bed and fall mat, but was observed in bed with the bed in a high position and the fall mat folded against the wall. Staff confirmed that the prescribed fall prevention interventions were not in place at the time of observation. These findings demonstrate a failure to follow established care plans and policies for fall prevention and accident hazard mitigation for multiple residents.
Failure to Administer Insulin as Ordered and Document Timely Administration
Penalty
Summary
A deficiency was identified when a resident with type 2 diabetes, severe obesity, dementia, and bilateral lower limb amputations did not consistently receive insulin as ordered. The resident was cognitively intact and required insulin administration per a physician's sliding scale and scheduled long-acting insulin at bedtime. Documentation and interviews revealed that the resident did not receive his evening insulin dose on one occasion, with the MAR indicating a refusal that the resident denied. Additionally, there were multiple instances where the evening long-acting insulin was administered outside the prescribed 7:00 P.M. to 11:00 P.M. window, including one dose given at 3:08 A.M. the following day. Staff interviews confirmed that nurses did not always check previous MAR entries to verify timely administration and sometimes delayed or omitted doses if the resident was not immediately available, even when the resident was present in the facility. The DON and Regional Director of Clinical Services acknowledged that insulin was administered outside the accepted timeframe and that documentation did not always reflect the actual time of administration. The facility's policy required medications to be given within one hour of the prescribed time unless otherwise specified, and the safety data sheet for the insulin emphasized the importance of consistent timing to avoid increased risk of hypoglycemia. The resident reported feeling ignored when requesting insulin and sometimes feeling lightheaded, suggesting possible effects from missed or delayed doses. Review of the MAR for the previous two months showed a pattern of late administration of the evening insulin dose on several dates. The facility failed to ensure the resident was free from significant medication errors by not administering insulin as ordered and not accurately documenting administration times.
Failure to Follow Enhanced Barrier Precautions During Skin Care
Penalty
Summary
During a survey, it was observed that staff failed to follow enhanced barrier precautions (EBP) while providing skin care to a resident with multiple medical conditions, including hemiplegia, diabetes, and a feeding tube. The resident had a physician's order requiring EBP, specifically the use of gowns and gloves during high-contact care activities such as dressing changes and wound care. Despite clear signage on the resident's door and documented policy, both an LPN and a CNA provided direct care without donning the required personal protective equipment (PPE). They touched various items in the resident's environment and performed skin care without gloves or gowns. When questioned, the staff members incorrectly stated that the EBP signage applied to a neighboring resident and that PPE was not necessary for this resident. The Director of Nursing later confirmed that the resident did have current orders for EBP and that staff should have worn gowns and gloves during the care provided. Review of facility policy and posted signage further supported the requirement for PPE during high-contact care activities to prevent the transmission of multi-drug resistant organisms.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Westerville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westerwood Rehabilitation | 1.4 mi | ★★★★★ | 10 | 0 |
| Inniswood Health And Rehabilitation | 1.4 mi | ★★★★★ | 1 | 0 |
| Forest Hills Center | 1.8 mi | ★★★★★ | 6 | 0 |
| Buckeye Terrace Rehabilitation And Nursing Center | 2 mi | ★★★★★ | 10 | 0 |
| Landings Of Westerville Health And Rehab The | 2.6 mi | ★★★★★ | 2 | 0 |
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