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Deficiency Records for Windsor Care Center of Cheviot Hills

A list of the most recent deficiencies for Windsor Care Center of Cheviot Hills. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for Windsor Care Center of Cheviot Hills. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-04-08 2024-04-12 Y
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Health 2024-04-08 2024-04-12 Y
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Health 2023-12-26 2024-01-08 Y
List the names and contact information of those in the facility. Fire Safety 2023-11-29 2023-12-22 N
Implement emergency and standby power systems. Fire Safety 2023-11-29 2023-12-22 N
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Fire Safety 2023-11-29 2023-12-22 N
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Fire Safety 2023-11-29 2023-12-22 N
Have properly located and lighted "Exit" signs. Fire Safety 2023-11-29 2023-12-22 N
Provide properly protected cooking facilities. Fire Safety 2023-11-29 2023-12-22 N
Have properly installed hallway dispensers for alcohol-based hand rub. Fire Safety 2023-11-29 2023-12-22 N
Construct fire resistant interior walls. Fire Safety 2023-11-29 2023-12-22 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-11-29 2023-12-22 N
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Fire Safety 2023-11-29 2023-12-22 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2023-11-29 2023-12-22 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2023-11-29 2023-12-22 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2023-11-29 2023-12-22 N
Have power receptacles that are properly grounded. Fire Safety 2023-11-29 2023-12-22 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-11-29 2023-12-22 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-11-29 2023-12-22 N
Have proper medical gas storage and administration areas. Fire Safety 2023-11-29 2023-12-22 N
Reasonably accommodate the needs and preferences of each resident. Health 2023-11-17 2023-12-14 N
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Health 2023-11-17 2023-12-14 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2023-11-17 2023-12-14 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-11-17 2023-12-14 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-11-17 2023-12-14 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-11-17 2023-12-14 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-11-17 2023-12-14 N
Provide safe, appropriate pain management for a resident who requires such services. Health 2023-11-17 2023-12-14 N
Post nurse staffing information every day. Health 2023-11-17 2023-12-14 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-11-17 2023-12-14 N
Ensure medication error rates are not 5 percent or greater. Health 2023-11-17 2023-12-14 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-11-17 2023-12-14 N
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Health 2023-11-17 2023-12-14 N
Provide and implement an infection prevention and control program. Health 2023-11-17 2023-12-14 N
Implement a program that monitors antibiotic use. Health 2023-11-17 2023-12-14 N
Keep all essential equipment working safely. Health 2023-11-17 2023-12-14 N
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Health 2023-11-02 2023-12-01 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-09-08 2023-10-08 Y
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Health 2023-09-08 2023-10-08 Y
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Health 2023-09-08 2023-10-08 Y
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2023-09-08 2023-10-08 Y
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Health 2023-09-08 2023-10-08 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-08-29 2023-09-29 Y
Provide enough food/fluids to maintain a resident's health. Health 2023-08-29 2023-09-29 Y
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2023-08-08 2023-09-01 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-07-19 2023-08-19 Y
Reasonably accommodate the needs and preferences of each resident. Health 2023-03-22 2023-04-22 Y
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2023-03-17 2023-04-16 Y
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2023-03-17 2023-04-16 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-03-24 2023-04-10 Y
Provide or obtain dental services for each resident. Health 2023-03-24 2023-04-10 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2023-03-24 2023-04-10 Y
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Health 2022-11-11 2022-12-11 Y
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2022-10-14 2022-11-14 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-09-23 2022-10-21 Y
Provide for the safe, appropriate administration of IV fluids for a resident when needed. Health 2022-09-23 2022-10-21 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-08-31 2022-09-28 Y
Provide enough food/fluids to maintain a resident's health. Health 2022-08-31 2022-09-28 Y
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Health 2022-04-10 2022-04-22 Y
Ensure that residents are free from significant medication errors. Health 2022-03-12 2022-03-22 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-03-06 2022-03-16 Y
Ensure residents have reasonable access to and privacy in their use of communication methods. Health 2022-02-13 2022-02-24 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2022-01-10 2022-01-20 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-12-29 2022-01-10 Y
Ensure that residents are fully informed and understand their health status, care and treatments. Health 2021-04-30 2021-05-25 N
Keep residents' personal and medical records private and confidential. Health 2021-04-30 2021-05-25 N
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2021-04-30 2021-05-25 N
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Health 2021-04-30 2021-05-25 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2021-04-30 2021-05-25 N
Assess the resident when there is a significant change in condition Health 2021-04-30 2021-05-25 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2021-04-30 2021-05-25 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2021-04-30 2021-05-25 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2021-04-30 2021-05-25 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-04-30 2021-05-25 N
Provide appropriate foot care. Health 2021-04-30 2021-05-25 N
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Health 2021-04-30 2021-05-25 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-04-30 2021-05-25 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2021-04-30 2021-05-25 N
Ensure that the resident and his/her doctor meet face-to-face at all required visits. Health 2021-04-30 2021-05-25 N
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2021-04-30 2021-05-25 N
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Health 2021-04-30 2021-05-25 N
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. Health 2021-04-30 2021-05-25 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2021-04-30 2021-05-25 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2021-04-30 2021-05-25 N
Ensure that residents are free from significant medication errors. Health 2021-04-30 2021-05-25 N
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2021-04-30 2021-05-25 N
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Health 2021-04-30 2021-05-25 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2021-04-30 2021-05-25 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-04-30 2021-05-25 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2021-04-30 2021-05-25 N
Provide and implement an infection prevention and control program. Health 2021-04-30 2021-05-25 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2021-04-30 2021-05-25 N
Follow proper procedures when the fire alarm was out of service for more than 4 hours. Fire Safety 2021-04-30 2021-05-20 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2021-04-30 2021-05-20 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2021-04-30 2021-05-20 N
Ensure that residents are fully informed and understand their health status, care and treatments. Health 2019-05-06 2019-05-29 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2019-05-06 2019-05-29 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2019-05-06 2019-05-29 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2019-05-06 2019-05-29 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2019-05-06 2019-05-29 N
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Health 2019-05-06 2019-05-29 N
Provide safe, appropriate pain management for a resident who requires such services. Health 2019-05-06 2019-05-29 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2019-05-06 2019-05-29 N
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Health 2019-05-06 2019-05-29 N
Implement a program that monitors antibiotic use. Health 2019-05-06 2019-05-29 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2019-05-06 2019-05-29 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2019-05-08 2019-05-24 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2019-05-08 2019-05-24 N
Ensure proper usage of power strips and extension cords. Fire Safety 2019-05-08 2019-05-24 N
Have proper medical gas storage and administration areas. Fire Safety 2019-05-08 2019-05-24 N

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