Inspection Reports for Cheshire House

The inspection visit was conducted as a complaint investigation related to Complaint Investigation #2632376.

Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection, as noted in an attached violation letter dated 2025-11-14.

Complaint Investigation #2632376 was the basis for the inspection. Violations were substantiated as violations were identified during the inspection.

An unannounced visit was conducted at Cheshire House Health Care Facility and Rehabilitation Center on October 20, 2025, by the Department of Public Health to investigate a complaint regarding an allegation of abuse involving Resident #1.

The investigation found that the facility failed to report an allegation of abuse to the Administrator or designee within two hours of the incident as required by policy. Resident #1, diagnosed with dementia and behavioral disturbances, was involved in an incident witnessed by nurse aides. The Director of Nursing confirmed the delay in reporting the allegation contrary to facility policy.

Complaint #2632376 involved an allegation of abuse by a nurse aide towards Resident #1. The allegation was not reported within the required two-hour timeframe, violating facility policy. Resident #1 no longer resides in the facility. The complaint was substantiated by the investigation.

A desk audit was conducted to review the implementation of the Plan of Correction for violations previously cited in a violation letter dated 2025-05-22.

All 15 violations identified in the prior inspection were corrected as of 2025-06-20. The Director of Nursing Services was notified of the corrections on 2025-07-01.

The inspection was conducted as a renewal licensing inspection and included a complaint investigation for complaint numbers 32774 and 43508.

Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified during the inspection. An attached violation letter dated 2025-05-22 was referenced.

Complaint investigation numbers 32774 and 43508 were part of the inspection process.

The inspection was conducted as a renewal licensing inspection and included a complaint investigation for complaint numbers 32774 and 43508.

The report indicates that violations of the General Statutes of Connecticut and/or regulations were not identified at the time of this inspection.

Complaint investigation numbers 32774 and 43508 were reviewed, but no violations were identified.

Unannounced visits were made to Cheshire House Health Care Facility & Rehab Center concluding on April 22, 2025, for multiple investigations and a licensing renewal inspection by the Department of Public Health.

The report details multiple violations of Connecticut State regulations including failures in notifying residents and families about physician-ordered testing and results, improper storage of wheelchairs, failure to report allegations of mistreatment and misappropriation of property, inadequate care planning for falls, nutrition, wound care, medication administration, and infection control practices.

The inspection visit was conducted as a desk audit to review the implementation of a Plan of Correction for a prior violation letter dated 2025-02-28.

The desk audit found that Violation #1 and another unspecified violation were corrected as of 2025-03-21. The Director of Nursing was notified of the corrections on 2025-04-02.

The inspection was a desk audit and follow-up to verify correction of previous violations.

Violations identified in a prior inspection were found to be corrected as of 3/31/2025, and the DNS was notified of the corrections on 4/2/2025.

The inspection visit was a desk audit conducted to review the implementation of a Plan of Correction for a prior violation letter dated 2025-03-13.

Violations identified in the previous inspection were found to be corrected as of 2025-03-31. The DNS was notified of the corrections on 2025-04-02 at 11:18 AM.

The inspection was conducted as a complaint investigation related to Complaint #43083.

Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.

Complaint investigation #43083 was the reason for the visit; violations were substantiated as noted.

An unannounced visit was made to Cheshire House Health Care Facility on February 24, 2025, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation related to Complaint CT #43083.

The investigation found that Resident #1, diagnosed with bacteremia, carcinoma of the liver, and diabetes mellitus, experienced a change in mental status and a critical low blood glucose level was not properly assessed or documented by nursing staff, including the Director of Nursing. The facility failed to obtain a fingerstick blood glucose level at the time of the resident's condition change, which was a deficient practice.

Complaint CT #43083 triggered the investigation. The complaint involved failure to assess and document blood sugar levels for Resident #1 during a change in mental status. The complaint was substantiated as the facility did not properly assess or document the critical blood glucose level.

The inspection was a desk audit conducted as part of the renewal licensing process for the facility.

The facility was found to be back into compliance as of 12/30/2024, with no violations identified at the time of this desk audit inspection.

A Complaint Investigation Survey was conducted at Cheshire House Health Center on January 8 and 9, 2025, to determine compliance with 42 CFR Part 483 requirements for long term care facilities.

Deficiencies and/or violations were cited as a result of this survey.

Complaint Investigation Survey with ACT Reference Numbers CT #42360 and #42429.

The inspection was conducted as a complaint investigation related to complaint investigation CT#41453 & CT#41507, focusing on multiple investigations of regulatory compliance at Cheshire House Health Care Facility.

The inspection identified multiple violations including missing controlled substance disposition records for several residents, failure to address hospital discharge recommendations, lack of resident identification bracelets, and issues with medication administration and documentation. Plans of correction were outlined for each violation.

The visit was complaint-related, investigating complaints #40447 and #41685. The Department of Consumer Protection and Drug Enforcement Division were notified regarding missing controlled substance records. The violations were substantiated and plans of correction were required.

The inspection was conducted as a renewal licensing inspection for the facility.

Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified during the inspection. The report references an attached violation letter dated 6/2/23.

The inspection visit was conducted as a complaint investigation triggered by Complaint Investigation # CT 00032882 to assess compliance with regulations and statutes.

Violations of the General Statutes of Connecticut and regulations were identified related to failure to ensure resident choice was honored regarding care provider requests, specifically involving Resident #1 and staff assignments.

Complaint Investigation # CT 00032882 was substantiated with violations identified related to resident care and staff conduct.

The inspection was conducted as a complaint investigation related to Complaint Investigation #32465 and violations of Connecticut State Agencies regulations were identified during the inspection.

The facility failed to ensure a resident was free from misappropriation of property after Resident #1's phone went missing and was later found to have been taken and sold by a staff member. The investigation included interviews, review of records, and identified misappropriation by NA #4.

Complaint Investigation #32465 was substantiated with violations identified related to misappropriation of Resident #1's property by a staff member (NA #4).

The inspection visit was conducted as a complaint investigation related to Complaint Investigation #CT 31668.

Violations of the General Statutes of Connecticut and/or regulations were identified during the inspection. The facility was toured, residents were observed to be well-groomed, and no concerns related to resident safety or infection control were identified. Staffing was reviewed and found to meet minimum state requirements.

Complaint Investigation #CT 31668 was the basis for the visit. Violations were identified but specific substantiation status is not stated.

An unannounced inspection was conducted for the purpose of conducting a complaint investigation for CT 31668.

The facility was observed to have well-groomed residents with no concerns related to resident safety or infection control. Staffing met minimum state requirements. Violations were identified related to failure to ensure staff accompanied a resident to a physician's appointment.

Complaint investigation #CT 31668 was conducted. Violations were substantiated as violations of Connecticut State Agencies regulations were identified.

A Complaint Investigation Survey was conducted to determine compliance with 42 CFR Part 483 requirements for long Term Care Facilities at Cheshire House Health Care Center.

The facility failed to ensure that staff accompanied a resident with severe cognitive impairment and extensive assistance needs to a scheduled off-site physician appointment, resulting in the resident attending the appointment alone.

The complaint investigation found that Resident #1, who had severe cognitive impairment and required extensive assistance with transfers, was not accompanied by staff to a medical appointment on 2/3/2022 as required. Interviews with nursing staff and the scheduler confirmed the failure. The facility's transportation policy requires accompaniment by a certified nurse assistant for such residents.

A desk audit was conducted on 11/9/21 by a representative of the FLIS for the purpose of reviewing the Plan of Correction (POC) for the violation letter dated 8/24/21.

The review of information identified that the violation of Infection Prevention & Control has been corrected. No violations of the General Statutes of Connecticut and/or regulations were identified at the time of this inspection.

An unannounced visit was made to Cheshire House Health Care Facility on October 7, 2021, for the purpose of conducting a complaint investigation related to violations of Connecticut State Agencies regulations.

Violations were identified related to failure to ensure proper use of gait belts during resident transfers, inadequate staff education, and failure to prevent resident injury. Additional findings included issues with infection control and failure to ensure appropriate seating of vaccinated and unvaccinated residents.

The visit was triggered by Complaint Investigation #30839. The complaint involved allegations of improper resident transfers causing injury, failure to use gait belts, and mistreatment of residents. The complaint was substantiated with violations identified during the inspection.

An unannounced visit was made to Cheshire House Health Care Facility on October 7, 2021, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation related to complaint #30839.

The facility failed to ensure a gait belt was utilized when transferring Resident #1 who required assistance with getting in and out of bed and chair, resulting in pain due to improper transfer techniques by nurse aides. The facility provided education to staff and implemented a plan of correction including audits and monitoring to prevent recurrence.

Complaint #30839 triggered the investigation. The complaint was substantiated as the facility was found noncompliant with transfer procedures for Resident #1.

Visit or revisit for the purpose of a Federal Comparative Survey conducted on 8/24/21.

A tour of the facility and review of clinical records, policies, documentation, and interviews were conducted. Nurse and NA staffing met the minimum regulatory requirements. Deficiencies F 600 and F 609 were corrected and brought back into compliance.

An unannounced visit was made to Cheshire House Health Care Facility on August 24, 2021, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a Focused Infection Control survey.

The facility failed to ensure appropriate seating of vaccinated and unvaccinated residents and failed to ensure weekly COVID-19 testing of seven identified unvaccinated staff members. The facility was also unaware of the requirement for weekly testing of unvaccinated staff according to the Governor's Executive Order 13A effective 8/11/21.

Unannounced visits were made to Cheshire House Health Care Facility to conduct a recertification survey and multiple complaint investigations.

The report details multiple violations of Connecticut State Agencies regulations identified during the visits, including failures in resident care, food service, documentation, abuse prevention, and infection control. The facility was required to submit a plan of correction addressing these deficiencies.

The visit included multiple complaint investigations as referenced by complaint numbers #29673, 29155, 26280, 25425, 30078. Allegations included abuse, mistreatment, neglect, and failure to provide adequate care. Some allegations were not substantiated due to lack of evidence or mitigating circumstances.

An unannounced visit was made to Cheshire House Health Care Facility on July 24, 2020 for the purpose of conducting a COVID-19 infection control monitoring visit and an investigation.

The facility failed to revise the care plan for a resident at risk for skin breakdown to address the need to offload the resident's heels to prevent a deep tissue injury or pressure ulcer. Documentation and care interventions related to offloading the heels were inadequate, resulting in the resident developing a deep tissue injury to the right heel.

Complaint #28016. The visit was complaint-related as indicated by the complaint number and investigation purpose. Substantiation status is not stated.

The inspection was an unannounced visit conducted on July 24, 2020, for the purpose of a COVID-19 infection control monitoring visit and complaint investigation #28016.

The facility was found to have violations of Connecticut State regulations related to infection control and failure to implement interventions to prevent pressure ulceration to a resident's heel. A deficiency was identified related to pressure ulcer prevention.

Complaint Investigation #28016 was substantiated with a deficiency identified related to pressure ulcer prevention.

A Complaint Investigation Survey and a COVID-19 Focused Survey were conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including infection prevention and control practices to prevent COVID-19 transmission.

The facility failed to revise the care plan for a resident at risk for skin breakdown to address the need to offload heels to prevent pressure ulcers. Documentation did not reflect offloading interventions, and a deep tissue injury was present on admission to the hospital. Nursing staff education and audits were planned to address the deficiency.

The visit was complaint-related under ACTS Reference Number CT #00028016. A deficiency was cited related to pressure ulcer prevention and care.

The document is a Plan of Correction responding to a violation related to failure to revise the care plan to prevent pressure ulcers in a resident at risk.

Resident #1 was at significant risk for pressure ulcers but the care plan failed to address offloading the resident's heels, resulting in a deep tissue injury to the right heel. Documentation and interventions were inadequate to prevent pressure ulcer development.

A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.

No deficiencies were cited as a result of this COVID-19 Focused Infection Control Survey.

A COVID-19 Focused Survey was conducted on June 19 and 24, 2020 to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including infection prevention and control practices to prevent COVID-19 transmission.

The facility failed to ensure a contract for removal and disposal of regulated biomedical waste was in place, resulting in several months of accumulated biomedical waste in the storage room. The waste was removed after the survey and a new contract and policy were implemented.

Unannounced visits were made to Cheshire House Health Care Facility on June 19 and 24, 2020 for the purpose of conducting a COVID-19 focused infection control survey.

The facility failed to ensure a contract for removal and disposal of regulated biomedical waste was in place, resulting in several months of accumulated biomedical waste in the storage room. The waste was removed following the inspection and a weekly pick-up schedule was implemented.

Unannounced visits were made to Cheshire House Health Care Facility on June 19 and 24, 2020 by representatives of the Department of Public Health for the purpose of conducting a COVID-19 focused infection control survey.

The inspection found excessive accumulation of biomedical waste in the storage room, including multiple full biohazard containers and bags on the floor, due to a lapse in waste removal since January 2020. The facility had not been aware of the issue until shortly before the inspection and lacked a biomedical waste policy. The waste was removed on June 19, 2020, and a weekly pick-up schedule was implemented.

A Complaint Investigation Survey and a COVID-19 Focused Survey were conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including infection prevention and control practices to prevent COVID-19 transmission.

No deficiencies were cited as a result of this survey.

Complaint Investigation Survey, ACTS Reference Number CT00027726. No deficiencies were cited.

A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.

No deficiencies were cited as a result of this COVID-19 Focused Survey.

A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including infection prevention and control practices to prevent COVID-19 transmission.

The facility failed to timely institute transmission-based precautions and isolate or cohort three residents with COVID-19 symptoms according to CDC guidelines, resulting in delayed isolation and potential spread of infection.

An unannounced visit was conducted at Cheshire House Health Care Facility to investigate compliance with state regulations and additional information received through April 21, 2020.

The facility failed to timely institute transmission-based precautions and isolate or cohort three of nine residents with symptoms of COVID-19 according to CDC guidelines, resulting in a violation of Connecticut state regulations related to infection control and nursing oversight.

The visit was complaint-related, focusing on infection control practices regarding COVID-19. The report does not explicitly state substantiation status.

The inspection was conducted as a complaint investigation based on complaint numbers 23874, 24284, and 24409, involving violations of Connecticut General Statutes and regulations identified during the inspection.

Violations were identified related to neurological assessments, medication administration, resident care, and documentation. The facility was found noncompliant in several areas including failure to document neurological assessments, medication errors, and inadequate nursing staff assistance.

Complaint investigation based on complaints #23874, 24284, and 24409. Violations were substantiated as noted in the attached violation letter dated 3/21/19.

The inspection was conducted as a renewal licensure and certification inspection with unannounced visits on March 4, 5, 6, and 7, 2019, by representatives of the Facility Licensing and Investigations Section of the Department of Public Health.

Violations of the General Statutes of Connecticut and regulations were identified during the inspection, with a written notice of noncompliance issued. The facility was required to submit a plan of correction by April 16, 2019. The inspection included review of policies, clinical records, and staff education, with findings related to pressure ulcer care, MDS assessment submissions, and notification procedures.

Unannounced visits were made to Cheshire House Health Care Facility on March 4, 5, 6 and 7, 2019 by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation, a licensure and a certification inspection.

The facility was found to have violations related to failure to notify resident representatives about a right heel blister, failure to submit residents' MDS assessments within required timeframes, and failure to implement offloading prior to the development of a pressure ulcer on a resident's heel. Documentation and clinical record reviews identified multiple deficiencies in care and communication.