Deficiency Records for Windsor Care Center of Cheviot Hills
Updated as of March 01, 2024
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? |
|---|---|---|---|---|
| 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 |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-08-13 | 2021-08-27 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-12 | 2021-07-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-06 | 2021-07-19 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-07-06 | 2021-07-19 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2021-05-27 | 2021-06-08 | 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 |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2021-04-05 | 2021-04-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-12 | 2021-04-14 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-03-12 | 2021-04-14 | Y |
| 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 |
