Cheviot Hills Post Acute

In the surveyor’s words

From the most serious findings on record at Cheviot Hills Post Acute, in the surveyor’s own words.

• Immediate jeopardy, widespreadF584Mar 17, 2023

  Based on observation, interview, and record review, the facility failed to have a system to ensure all 15 of 15 heating, ventilation, and air conditioning (HVAC) units were operational and provided heat to maintain comfortable and appropriate room temperature according to the facility's policy and procedures, titled Room Temperature Policy & Procedure, for 80 of 80 residents. This deficient practice had the potential to cause serious harm for the residents and risk for pneumonia (Infection that inflames air sacs in one or both lungs, which may fill with fluid), cardiac arrest (sudden, unexpected loss of heart function, breathing, and consciousness), and death related to hypothermia (a significant and potentially dangerous drop in body temperature). […]

• Immediate jeopardy, isolatedF803Sep 8, 2023

  Based 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). […]

• Actual harm, isolatedF689Nov 8, 2024

  Based 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). […]

• Actual harm, isolatedF677Jul 6, 2021

  Based on observation, interview, and record review, the facility failed to ensure four of four sampled residents, (Residents 1, 2, 3, and 4), who needed assistance with transfers, toilet use, bathing and personal hygiene, received assistance with personal and oral hygiene and toileting needs within five minutes, and soiled bed linen change. This deficient practice resulted in: 1. Residents 1 remained wet in urine and / or bowel movements for extended periods of time, became upset, was crying due to the lack of care and left the facility against medical advice (AMA) 22 days from admission. 2. Resident 2 had to urinate on the incontinent brief despite being able to control because staff did not assist him to use the toilet, which caused Resident 2 to be upset, helpless, and frustrated. 3. […]

• Actual harm, isolatedF690Jul 6, 2021

  Based on observation, interview and record review, the facility failed to provide incontinence (inability to feel and control urination and bowel movements) care for two of four sampled residets (Residents 1 and 2) who used briefs and were assessed to be incontinent of bowel and bladder (B&B). This deficient practice resulted in Residents 1 and 2 remaining wet and or soiled for extended periods of time, becoming upset, and was compelled to leave the facility against medical advice (AMA, when a person chooses to leave an institution before the treating physician recommends discharge), and had the potential had to place Residents 1 and 2 at risk for skin breakdown and urinary tract infections. Findings: 1. […]