Inspection Reports for Cheshire Home
9 Ridgedale Ave, Florham Park, NJ, 07932
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 20, 2025, did not identify any deficiencies. Earlier inspections showed multiple deficiencies related to resident care, including pressure ulcer management, medication administration, and infection control, as well as life safety code issues such as fire safety system maintenance and smoke barrier integrity. Complaint investigations in 2023 substantiated concerns about inadequate RN coverage and medication availability, which affected resident care. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows improvement, with the most recent survey free of deficiencies after several prior reports noted various issues.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
8.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
58% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
31 residents
Based on a September 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Notice
Deficiencies: 0
Date: Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice explains the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 18
Date: Sep 6, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to reasonable accommodations, abuse/neglect policies, pressure ulcer care, incontinence care, respiratory care, nurse staffing information, drug regimen review, laboratory services, infection prevention and control, life safety code compliance including egress doors, exit signage, cooking facilities, fire alarm and sprinkler system maintenance, smoke compartment integrity, and fire door inspections.
Deficiencies (18)
Facility failed to ensure resident's call light was readily accessible within reach.
Facility failed to ensure reference checks were completed for newly hired staff prior to employment.
Facility failed to provide care consistent with professional standards for residents with pressure ulcers, including risk assessment and documentation.
Facility failed to provide appropriate storage and care of urinary drainage bags for a resident.
Facility failed to ensure respiratory care equipment was changed as per physician orders and suctioning care was provided according to standards.
Facility failed to post nurse staffing information daily for two of four days during the survey.
Facility failed to identify irregularities in medication administration related to PRN pain medications for one resident.
Facility failed to ensure timely laboratory services and follow-up on lab recommendations for one resident.
Facility failed to ensure newly hired employees completed required two-step Mantoux tuberculin skin test upon hire.
Facility failed to ensure doors in required means of egress were not equipped with latches or locks requiring a tool or key from the egress side.
Facility failed to ensure doors permitted to be held open self-close upon loss of power to the hold open device.
Facility failed to ensure exit signage was visible and directional indicators were properly located.
Facility failed to ensure cooking equipment was protected and maintained in accordance with NFPA standards, including grease buildup on spray nozzles.
Facility failed to follow appropriate hand hygiene, use of PPE, and disinfect equipment practices for staff and failed to prevent potential spread of infection in laundry areas.
Facility failed to ensure semi-annual fire alarm system inspections, testing and maintenance were conducted timely.
Facility failed to ensure quarterly fire sprinkler system inspection, testing and maintenance was conducted timely.
Facility failed to ensure fire door assemblies were inspected and tested annually.
Facility failed to ensure smoke barriers were continuous through all concealed spaces.
Report Facts
Census: 31
Sample size: 12
PRN medication administration discrepancies: 45
PRN medication administration discrepancies: 20
PRN medication administration discrepancies: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Certified Nursing Aide | Failed to complete required two-step Mantoux tuberculin skin test upon hire |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Unaware of proper care and storage of urinary drainage bags |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Unaware of proper care and storage of urinary drainage bags |
Inspection Report
Routine
Deficiencies: 9
Date: Sep 6, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including resident care, staff practices, medication management, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure resident call lights were accessible, incomplete reference checks for new staff, inadequate pressure ulcer care and documentation, improper urinary drainage bag care, failure to change respiratory equipment as ordered, incomplete medication administration documentation, failure to post nurse staffing information timely, failure to follow lab orders, and lapses in infection prevention and control practices.
Deficiencies (9)
Failure to ensure that the resident's call light was readily accessible within reach for Resident #1.
Failure to ensure reference checks were completed for two newly hired staff prior to their start date.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for Residents #8 and #9, including lack of formal risk assessment and inconsistent wound documentation.
Failure to provide appropriate care for urinary drainage bags for Resident #15, including uncovered drainage bag and lack of resident education documentation.
Failure to ensure nebulizer setup and suction tubing were changed as per physician orders for Resident #11.
Failure to post daily nurse staffing information for two of four days during the survey.
Failure to ensure a licensed pharmacist identified irregularities in medication administration for Resident #21, specifically PRN Acetaminophen not administered with PRN Oxycodone as ordered.
Failure to ensure timely laboratory services/tests were performed as ordered for Resident #21, including psychiatric recommendations and routine labs.
Failure to follow appropriate hand hygiene, use of personal protective equipment, disinfect equipment practices, and infection control practices for staff and laundry areas.
Report Facts
PRN Acetaminophen not administered: 45
PRN Acetaminophen not administered: 20
PRN Acetaminophen not administered: 7
PRN Acetaminophen administered: 32
PRN Acetaminophen administered: 47
PRN Acetaminophen administered: 2
PRN Oxycodone administered: 77
PRN Oxycodone administered: 67
PRN Oxycodone administered: 9
Urine output entries with 400+: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Cared for Resident #15 and discussed urinary drainage bag care |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Cared for Resident #15 and discussed urinary drainage bag care |
| Registered Nurse Supervisor/Infection Preventionist #1 | Registered Nurse Supervisor/Infection Preventionist | Interviewed regarding wound care and infection control findings |
| Registered Nurse Supervisor/Infection Preventionist #2 | Registered Nurse Supervisor/Infection Preventionist | Interviewed regarding wound care and infection control findings |
| Licensed Practical Nurse | Licensed Practical Nurse | Interviewed regarding medication administration irregularities |
| Consultant Pharmacist | Consultant Pharmacist | Responsible for monthly medication regimen review |
| Physical Therapist | Physical Therapist | Observed using gloves improperly and not disinfecting equipment |
| District Manager | District Manager | Contracted laundry services, interviewed during laundry area tour |
| Chief Officer | Chief Officer | Contracted laundry services, interviewed during laundry area tour |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 2
Date: Aug 18, 2023
Visit Reason
The inspection was conducted due to complaints regarding lack of continuous Registered Nurse (RN) coverage and medication availability issues affecting residents' care and treatment.
Complaint Details
The complaint involved allegations of inadequate RN coverage and medication availability. The facility was found to have no RN coverage for eight continuous hours on multiple weekend dates in early 2023. A resident reported severe pain and medication unavailability, and a call was received from the resident's father alleging abuse and neglect related to medication delays.
Findings
The facility failed to ensure an RN was on duty for eight continuous hours on multiple weekend dates, potentially affecting all 32 residents. Additionally, the facility failed to provide timely medication, specifically pain medication (oxycodone), to a resident due to lack of availability, causing pain management issues.
Deficiencies (2)
Failure to have a Registered Nurse on duty for eight continuous hours per day on weekends.
Failure to ensure medication was consistently available, resulting in pain medication not administered to a resident due to lack of availability.
Report Facts
Residents affected: 32
Residents reviewed: 17
Resident ID: 24
Medication dosage: 10
Pain level: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed and confirmed lack of RN coverage and medication availability issues |
Inspection Report
Annual Inspection
Census: 32
Capacity: 35
Deficiencies: 7
Date: Aug 18, 2023
Visit Reason
A Recertification Survey was conducted on behalf of the New Jersey Department of Health from 08/14/23 through 08/17/23 to assess compliance with long term care facility regulations.
Findings
The facility was found not in substantial compliance with requirements including failure to ensure 8 continuous hours of RN coverage daily, medication availability issues, and multiple life safety code deficiencies related to building construction, fire safety systems, smoke barriers, and emergency power systems.
Deficiencies (7)
Failed to ensure a Registered Nurse (RN) was on duty for eight continuous hours per day, seven days a week.
Medication was not consistently available for one resident due to lack of availability in the facility.
Failed to provide a Life Safety Floor Plan identifying smoke barriers and construction type.
Interior wall finishes did not have a flame spread rating in accordance with NFPA 101.
Smoke detection was not installed at the main fire alarm control panel in an area not continuously occupied.
Failed to ensure smoke barriers formed at least two smoke compartments with proper sealing and door mechanisms.
Emergency Power Supply (EPS) lacked a remote manual stop station to prevent inadvertent operation.
Report Facts
Survey Dates: 08/14/23 through 08/17/23
Survey Census: 32
Total Licensed Capacity: 35
Dates with no RN coverage for 8 continuous hours on weekends: 9
Sample Size: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding RN staffing and medication availability deficiencies |
| Asst Nursing Secretary | Assistant Nursing Secretary | Responsible for nursing staffing schedules and RN monitoring |
| Human Resources Director | Human Resources Director | Reviewed staffing policies and maintains RN monitoring logs |
| Inservice Coordinator | Inservice Coordinator | Inserviced nursing staff on medication ordering and fire safety procedures |
| Maintenance Director | Maintenance Director | Responsible for updating floor plans, fire safety compliance, and emergency power system corrections |
| Assistant Maintenance Director | Assistant Maintenance Director | Confirmed lack of smoke detection at fire alarm control panel |
Inspection Report
Routine
Deficiencies: 4
Date: Nov 15, 2021
Visit Reason
The inspection was conducted to assess compliance with food handling, infection control, and COVID-19 prevention protocols in the facility's kitchen and nursing units.
Findings
The facility failed to properly handle and store potentially hazardous foods, maintain kitchen equipment and infection control practices, and identify and quarantine unvaccinated residents exposed to COVID-19. Multiple food items were unlabeled or undated, kitchen equipment was unclean, and staff did not consistently follow infection control policies. The facility also did not implement quarantine measures for unvaccinated residents exposed to COVID-19 as required by guidelines.
Deficiencies (4)
Failure to properly handle and store potentially hazardous foods, including unlabeled and undated food items in the kitchen.
Failure to maintain equipment and kitchen areas to prevent microbial growth and cross contamination, including dirty ovens, wet nested pans, and unclean meat slicer.
Failure to maintain adequate infection control practices in the kitchen, including staff not wearing beard restraints and improper sanitizer concentration.
Failure to identify unvaccinated residents exposed to COVID-19 as Persons Under Investigation and failure to implement quarantine and updated Viral Outbreak Response Plan.
Report Facts
Residents fully vaccinated: 31
Unvaccinated residents exposed to COVID-19: 3
Sanitizer concentration: 50
Food items observed: 9
Food item weights: 10
Food item weights: 5
Food item weights: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Dietary | Director of Dietary | Acknowledged food labeling and storage deficiencies during kitchen tour |
| Director of Nursing | Director of Nursing | Provided information on COVID-19 positive staff and outbreak response |
| Inservice Coordinator | Inservice Coordinator | Completed contact tracing for COVID-19 positive CNA |
| Registered Charge Nurse | Registered Charge Nurse | Described monitoring and isolation practices for residents exposed to COVID-19 |
| Licensed Practical Nurse | Licensed Practical Nurse | Reported staff PPE use and resident mask wearing on nursing unit |
| Infection Preventionist | Infection Preventionist | Discussed PPE use and outbreak testing policy |
| Administrator | Administrator | Reviewed and updated the facility's Outbreak Response Plan |
| Assistant Administrator | Assistant Administrator | Participated in review and update of Outbreak Response Plan |
Inspection Report
Follow-Up
Census: 33
Deficiencies: 1
Date: Nov 15, 2021
Visit Reason
The inspection was conducted to assess compliance with New Jersey's minimum direct care staff-to-resident ratios as mandated by state law, following concerns about staffing levels on specific day shifts.
Findings
The facility failed to maintain the required minimum direct care staff-to-resident ratios on 2 of 14 day shifts reviewed, specifically on 10/31/21 and 11/02/21 where the number of CNAs was below the required minimum. The facility acknowledged staffing challenges and implemented a plan of correction including monitoring schedules, in-service training, and active recruitment of CNAs.
Deficiencies (1)
Failure to maintain the required minimum direct care staff-to-resident ratios on 2 of 14 day shifts reviewed.
Report Facts
Residents on day shift: 33
Certified Nurse Aides (CNAs) present: 4
Residents on day shift: 34
Certified Nurse Aides (CNAs) present: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Human Resources Director | In charge of staffing and monitoring compliance with minimum staffing requirements | |
| Assistant Nursing Secretary | Assists with staffing and monitoring compliance | |
| Director of Nursing | Informed of staffing concerns and responsible for reviewing nursing schedules weekly | |
| Assistant Administrator | Made aware of staffing concerns | |
| Administrator | Made aware of staffing concerns |
Inspection Report
Routine
Census: 35
Deficiencies: 0
Date: Nov 23, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
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