Cheviot Hills Post Acute

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its' policy and procedures (P&P) titled, Transfer or Discharge, reviewed 10/20/2025 by failing to ensure that orientation was provided to the Responsible Party (RP 1) for one of the three sampled residents (Resident 1) who had a history of falls and a high fall risk when she (Resident 1) was discharged to her home under the care of RP 1. This deficient practice placed Resident 1 at risk for falls. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure the residents and/or responsible party (RP) were informed in advance, of the risks and benefits of Quetiapine (Seroquel - a prescription medication used to treat mental health conditions by balancing certain natural substances - neurotransmitters in the brain) for one of three sampled residents (Resident 1). This deficient practice violated the residents' right to make an informed decision regarding the use of Seroquel. [...]

Inspectors wroteBased on observation, interview, and record review the facility to develop and implement and individualized and comprehensive care plan for one out of three sampled residents (Resident 1), who was on Quetiapine (Seroquel - a prescription medication used to treat mental health conditions by balancing certain natural substances - neurotransmitters in the brain) and monitoring for psychotic behaviors manifested by inconsolable screaming. This deficient resulted in Resident 1's behaviors being unmonitored as well as unmonitored adverse drug reactions (undesired and harmful effects that occur because of a medication, treatment, or procedure). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that annual performance review was completed for that one of two Certified Nursing Assistant (CNA) 7 according to facility's policy and procedures (P&P) titled Performance Evaluations, reviewed 10/20/2025. This deficient practice had the potential to result in facility staff to not meet standards of practice, duties and responsibilities and possibly cause harm to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe its written standards, policies and procedures for infection control measures by failing to adhere to infection prevention standards for two out of five sampled residents Resident 71 and Resident 94) when: A. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs of one of five sampled residents (Resident 37) by failing to provide the resident a call device that the resident is able to use. This deficient practice had the potential for Resident 37 to be unable to call the facility staff for help when needed.

Inspectors wroteBased on observation, interview, and record review, the facility dietary staff failed to protect resident's right to privacy by tossing a meal ticket with a resident's name and room number dietary in the kitchen trash can for one of one resident (Resident 96). This deficient practice of failing to discard dietary document containing patient information in designated and secured location violate resident's right to privacy.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a homelike environment one of four sampled residents (Resident 60) when Resident 60's dignity curtain (bed side curtain) had multiple scattered round/smeared brown spots and the dignity curtain was changed during room deep cleaning on 2/7/2026 according to the facility's policy and procedures (P&P) titled , titled Quality of Life _Home like Environment, reviewed 10/20/2025. This deficient practice resulted in an environment that was unclean, not homelike and had the potential for infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the resident or their representative was notified timely in writing the facility's bed hold policy for one of four sampled residents (Resident 72). This deficient practice resulted in resident 72 and/or their representative not being aware of the facility's bed hold and reserve payment policy upon transfer to the hospital from the facility.

Inspectors wroteBased on observation and interview, the facility staff failed to provide an environment that is free from accidents and hazards by failing to ensure that staff did not pour and leave orange liquid bathing soap in cups that the residents use to drink fluids unattended inside residents bathroom for one of one resident (Resident 94) according to facility's policy and procedures titled Quality of care: Safety of Residents dated 10/20/2025. This deficient practice had the potential for the Resident 94 and residents who are confused and/or have wandering behavior to accidentally ingest the orange liquid bathing soap.

Inspectors wroteBased on observation, and interview, the facility failed to observe and maintain their infection control measures for one of four sampled residents (Resident 72) when Resident 70's nebulizer (a small electric machine that turns liquid medication into fine mist) tubing and mask was on Resident 72's night stand not stored in a plastic bag or labelled with a the residents name/date according to facility's policies and procedures (P&P), titled Infection Prevention and Control Program, reviewed 10/20/2025, and Administering Medication through a small Volume (Handheld) Nebulizer reviewed 10/2025. This deficient practice had the potential to cause infection and/or hospitalization for Resident 72.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's clinical record was maintained in accordance with accepted professional standards and practice that are accurate, by failing to document rehabilitative care (a set of medical and therapeutic interventions designed to help individuals regain, maintain, or improve physical, mental or cognitive abilities lost due to injury, illness, surgery or disability) in the Restorative Administrative Record for one out of two sampled residents (Resident 9) according to facility's policy and procedures (P&P) titled Charting and Documentation dated, 10/20/2025. This deficient practice had the potential to result in a lack and/or a delay in communication between the staff and cause an interruption in the provision of Restorative care/intervention for Resident 9.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a call button was within reach for one of five sampled residents (Resident 38) according to the facility's policy and procedures (P&P) titled, Call System Resident dated reviewed 10/20/2025. This deficient practice had the potential to result in delay of necessary care including emergency response for Resident 38.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement an individualized person-centered care plan for one of the three sampled residents (Resident 2) who was assessed to have dry skin to the face and Bilateral Lower Extremeties (BLE- both legs) upon admission. This deficient practice had the potential to result is further dryness, skin break, and infection. During a review of the admission record for Resident 2 indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including sequelae of cerebral infarction are the long-term problems or lasting effects that occur after a stroke (brain tissue death from blocked blood flow), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and heart failure (the heart can't pump enough oxygen-rich blood to meet the body's needs). [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure that one out of three sampled residents (Resident 2) who had dry skin to the face and both legs was assessed by a licensed nurse with a specific skill set within their scope. This deficient practice had the potential to result in skin breakdown and infection. During a review of the admission record for Resident 2 indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including sequelae of cerebral infarction are the long-term problems or lasting effects that occur after a stroke (brain tissue death from blocked blood flow), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and heart failure (the heart can't pump enough oxygen-rich blood to meet the body's needs). [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide necessary services to maintain good personal hygiene and grooming to one out of three sampled residents (Resident 1), by failing to ensure Resident 1 did not have excessive dry skin to the face and overgrown toenails. This deficient practice placed Residents 1 at risk for skin infections, skin breakdown, and poor self-perception.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an accurate assessment in the Minimum Data Set (MDS- a federally mandated resident assessment tool) was done for one of three sampled residents (Resident 1). This deficient practice had the potential to affect the resident's plan of care and delivery of services.

Inspectors wroteBased on interview and record review the facility failed to develop a care plan for OSA (Obstructive Sleep Apnea. It is a sleep disorder where the airway repeatedly collapses during sleep, causing breathing to stop or become shallow) for one of three sampled residents (Resident 1). This failure resulted in no plan of care for Resident 1's OSA and had the potential to affect continuity and delivery of care.

Inspectors wroteBased on interview and record review for one of three sampled residents (Resident 2), the facility failed to develop a care plan for the left foot treatments. This deficient practice had the potential to led to the development of redness to the left heel.

Inspectors wroteBased on observation, interview and record review for one of three sampled residents (Resident 2), the facility failed to monitor skin and report redness on Resident 2's left heel to the attending physician (AP). This deficient practice placed Resident 2 at risk of developing a pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) to the left heel.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary cooks followed the menu and used a recipe for lunch on 12/9/2024. This deficient practice the potential for the food to be prepared incorrectly and could make the residents sick.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen. These failures had the potential to result in harmful bacteria growth that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) for 89 of 89 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff promote dignity while assisting one of 20 sampled residents (Residents 66) during meals; by not feeding the resident at eye level to maintain face-to-face contact with the residents. This deficient practice had the potential to result in feelings of decreased self-esteem and self-worth for Residents 4.

Inspectors wroteBased on record review and staff interviews, the facility failed to complete and submit the annual comprehensive Minimum Data Set (MDS, a resident assessment tool) assessment within the regulatory timeframe for one of 18 sampled residents (Resident 40). This deficient practice had the potential to negatively affect the provision of necessary care and services for the affected residents.

Inspectors wroteBased on interview and record review, the facility failed to conduct a Preadmission Screening and Resident Review (PASRR- is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) level 1 assessment for one of four residents (Resident 50) diagnosed with mental illness. This deficient practice had the potential for inappropriate placement and management of Resident 50.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a Pre-admission Screening Resident Review level I (PASRR-an evaluation to determine if an induvial has a serious mental illness, intellectual disability, developmental disability, or related condition) was obtained and maintained in the residents chart for three of three sampled residents (Residents 1, 2, and 74). This deficient practice had the potential to negatively affect the appropriated care and services rendered and required for the residents.

Inspectors wroteBased on interview and record review, the facility failed to: 1. The Director of Nursing (DON) was knowledgeable on how prevent medication/narcotics and did not maintain a log/records of medications/narcotics (controlled medications used to treat moderate to severe pain) collected for disposal by a medication waste management company. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide social services to one out of 20 sampled residents (Resident 244) by failing to follow up on an order for orthopedic (musculoskeletal specialist) evaluation appointment. This deficient practice had the potential for delay in the delivery of care and services.

Inspectors wroteBased on observation and interview, the Director of Nursing (DON) failed to store, and discard controlled and non-controlled medications according to the facility's policy and procedures titled Discarding and Destroying Medications. These failures had the potential for diversion of medications.

Inspectors wroteBased on observation and interview, the facility failed to provide food that accommodates resident allergies, intolerances, and preferences. This deficient practice resulted in the Resident waiting over two hours for an alternative meal.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment by the inability of the facility to ensure a pest free environment for one of three residents, Resident 294. This deficient practice resulted in Resident 294 being bitten by a spider and also had the potential for facility wide infestation of spiders.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had a history of falls, and identified to have fall risk indicators was not left unattended sitting on bed by the Certified Nursing Assistant (CNA) 1 on 11/5/2024. This failure resulted in Resident 1 had a fall on 11/5/2024 at 12:12 am and was sent to General Acute Care Hospital (GACH) on 11/5/2024. Resident 1sustained a mildly displaced right 10th through 12th rib fracture and right 10th rib fracture is segmental (happen when one of your bones is broken in at least two places, leaving a segment of your bone totally separated by the breaks).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its' policy and procedure (P&P) by failing to ensure prompt physician notification of one of the three sample residents (Resident 2) when Resident 2 had chills on 10/18/2024 at 3:47 pm and 10/18/2024 at 11:49 pm. As a result of this deficient practice, Resident 2 was found to have Altered Mental Status (AMS -a change in mental function that stems from illnesses, disorders and injuries affecting your brain)and was transferred to General Acute Care Hospital (GACH) where she was diagnosed with sepsis (a life-threatening blood infection), Urinary Tract Infection (UTI- an infection in the bladder/urinary tract).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 2 (CNA 2) did not assist CNA 1 with the care for one of four residents (Resident 1) after Resident 1 refused for CNA 2 to provide/assist with Resident 1's care. This deficient practice violated Resident 1's right to make an informed decision regarding who will provide nursing care to Resident 1 prior to performing nursing care.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to protect the resident's right to be free from abuse for one of three Residents (Resident 1). As a result, on 4/5/24 Resident 2 punched Resident 1 (Resident 2's roommate) in the face, resulting in a cut to Resident 1's lip.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to obtain a physician ' s order for behavior monitoring and implement behavior monitoring for signs and symptoms of dementia ((loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) for one of three Residents (Resident 1). As a result, on 4/5/24 Resident 2 punched his roommate (Resident 1) in the face, resulting in a cut to Resident 1 ' s lip.

Inspectors wroteBased on Observation, interview, and record review, the facility failed to maintain a full time Director of Nursing (DON- registered nurse [RN]) and that a Licensed Vocational Nurse (LVN) did not assume the role of Assistant DON (ADON) without the direct supervision of a DON for the months of 2/2023 through 12/2023 for 78 of 78 residents in the building. This deficient practice had the potential to result in the facility inability to establish nursing standard of practices, compliance with the Stated and Federal agencies, handle emergencies in the facility, complete incident reports, initiate investigations on incidents and complete necessary forms, manage the entire nursing department and assume the responsibility for resident care in the absence of a physician, and the assume the responsibility of an Administrator in the absence of an Administrator.

Inspectors wroteBased on interview and record review, the facility failed to ensure advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were updated in the clinical records five out of five sampled residents (Resident 4, Resident 17, Resident 32, Resident 35, and Resident 60) by failing to maintain documentation of the residents' advance directives acknowledgement form in the residents' clinical records. This deficient practice had the potential to cause conflict with the residents' wishes regarding health care Resident 4, Resident 17, Resident 32, Resident 35, and Resident 60.

Inspectors wroteBased on interview and record review, for three of three sampled residents (Resident 17, Resident 66, and Resident 281), the facility failed to develop a comprehensive care plans for: 1. Chronic (ongoing) right knee pain for Resident 66 2. Antipsychotic medications (medications used to treat menlla illness) for Resident 281 3. Coffee ground emesis (vomit that looks like coffee grounds which is a sign of internal [inside] bleeding) for Resident 17 This deficient practice had a potential for Resident 17, Resident 66, and Resident 281 to not receive appropriate care and treatment.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure designated nursing staff would restock the Automated Drug Delivery System (ADDS, the facility used the brand, Cubex) within 48 hours of receiving the emergency medications supplies from the pharmacy. This deficient practice had the potential of drug diversion and/or delay in providing care to residents.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the medication error rates was not five (5) percent (%) or greater during medication administration observations. During the 29 opportunities of medication administration observations conducted, there were 6 errors, thus, the error rate was at 20.7%. Five of 6 errors were due to nurses crushing medication without physician orders, for Residents 67 and 14. The remaining 1 of 6 errors was due to the administration of the incorrect dosage form: Resident 21 had an order for aspirin (a medication to reduce risk of blood clots forming) oral capsule 81 milligrams (mg, an unit to measure mass), however, aspirin enteric coated (delay release coating to reduce stomach irritation) 81 mg tablet was administered. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Personal soda bottles were stored in the facility reach in refrigerator. 2. Three containers of fruit stored in the reach in refrigerator had no date and label. 3. Cook1 did not wash hands after removing soiled gloves and returned to food preparation area to cook food. 4. Cook1 prepared raw chicken in the food preparation sink and then used the same sink to wash raw vegetables. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another), leading to foodborne illness in 70 out of 78 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections when: 1. Resident's room air-conditioning ventilator had an excess of dirt particles. 2. Meal trays were observed in the parking lot next to trash and linen barrels. 3. A shower room had human feces on the floor and dirty linens on top of the dirty linen barrel. These deficient practices could result in the spread of infections to residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff responded to residents call lights promptly for one of three sampled residents (Residents 39). This deficient practice had the potential not to meet the needs of Resident 39.

Inspectors wroteBased on interview and record review, the facility failed to notify the residents representative of a change in condition for one of three sampled residents (Resident 17) in accordance with the facility's policy and procedures (P&P) titled change in condition (COC- a change in the resident's health or function) Notification of, with effective date of 8/25/2021. This deficient practice resulted in violation of resident's representatives right to be notified of a change in condition for Resident 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 21 sampled residents (Resident 75) was kept clean and free of odors by failing to provide personal hygiene, and incontinent care. This deficient practice resulted in Resident 75 feeling frustrated and embarrassed and the potential for odors, infection, unkempt matted hair, dry/broken skin, and poor hygiene.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of seven sampled residents (Residents 79) received care and services by failing to assess, monitor, and document a set of vital signs prior to the resident's death. This deficient practice had the potential to result in delayed appropriate care and treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a 16 ounce (oz - unit of measurement ) bottle of Isopropyl 70% Alcohol (rubbing alcohol - a colorless, flammable [easily set on fire] liquid) was not left at the bedside for one of 21 sampled residents (Resident 6). This deficient practice had the potential to result in fire related hazards and death for all residents, staff, and guests in the facility.

Inspectors wroteBased on observation, interview, and record review, the licensed nursing staff failed to assess the pain level (intensity) and manage pain for one of one sampled resident (Resident 20). This deficient practice resulted in Resident 20 experiencing unnecessary pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staffing information was posted and updated daily. As a result, the total number of staff and the actual hours worked by the staff was not readily accessible to residents and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 6), received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs, by failing to assess the source of Resident 6's itchy skin and notifying the doctor of a change in Resident 6's skin condition. This deficient practice had the potential for Resident 6 to have unresolved skin itching that could result in skin infection and unnecessary hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to implement an antibiotic stewardship program (a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics) to monitor antibiotic use for two of two sampled residents (Resident 21 and 79). This deficient practice had the potential for inappropriate use of antibiotics, placing residents at higher risk of antibiotic resistance (taking antibiotics too often or for the wrong reasons can change bacteria so much that antibiotics don't work against them).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the walk-in freezer was maintained in a good operating condition. The walk-in freezer had ice buildups inside, on the ceiling, floor, walls next to the door and the plastic door curtains (strip curtains used for temperature separation for door openings in refrigerators and freezers). There was ice buildup on the door and the parameters of the freezer door. Upon opening the door, a large thick chunk of ice fell to the floor and the freezer door was not closing tight. There were buildups of frost and ice crystals inside the food including ice crystals in the veggie patty and ice buildup in the bags of meat next to the entrance of the walk-in freezer. The freezer was operational in a manner that had the potential to affect food quality and /or increase the potential of growth of microorganism. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the facility pest free (free of cockroaches and flies), maintain room cleanliness, prevent pest harborage areas, and maintain an effective pest control program. This deficient practice had the potential to place all 72 residents residing in the facility at risk of vector-borne diseases (Illness that results from infections transmitted to humans by insects, such as cockroaches) if cockroaches and flies spread in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with dysphagia (inability to chew or difficulty swallowing) and at risk for choking received a diet in the correct form for one of 11 sampled residents (Residents 1). On 9/3/2023 at 5:24 p.m. Resident 1 was given a regular consistency diet (no food consistency/texture restrictions) instead of a prescribed puree diet (diet used in the dietary management of dysphagia with the food prepared moist, smooth, cohesive [sticking together] with no water separation and with consistency of a pudding). This failure had a potential to cause life threatening conditions such as choking, aspiration (inhaling small particles into the lungs), and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the facility in good repair, at all times. This deficient practice had the potential to result in accidents and negatively affect the health and safety of all residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the facility pest free (free of cockroaches and flies), maintain the kitchen area clean, prevent pest harborage areas, and maintain an effective pest control program. This deficient practice had the potential to place all 76 residents residing in the facility and receiving food or utensils from the kitchen at risk of vector-borne diseases (Illness that results from infections transmitted to humans by insects, such as cockroaches) if cockroaches and flies spread in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 11 out of 17 sampled residents (Resident 1, 2,3,4,5,6,7,8,9,10,11) were provided a therapeutic diets (diet ordered by a physician as part of treatment for disease or clinical condition, or to eliminate or decrease specific nutrients in the diet, or to increase specific nutrients in the diet, or to provide food the resident is able to eat) as ordered by the physician. These deficient practices had the potential to prevent the residents from receiving benefit of the therapeutic diet.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 11 sampled residents (Resident 1) remains free of accident hazards by failing to ensure Resident 1 with dysphagia (inability to chew or difficulty swallowing) received a diet in the correct form per physician order. On 9/3/2023 at 5:24 p.m., Resident 1 was given a regular consistency diet (no food consistency/texture restrictions) instead of a prescribed puree diet (diet used in the dietary management of dysphagia with the food prepared moist, smooth, cohesive [sticking together] with no water separation and with consistency of a pudding). This failure had a potential to cause life threatening conditions such as choking, aspiration (inhaling small particles into the lungs), and death.