Inspection Report Summary
The most recent inspection on October 20, 2025, found deficiencies related to a failure to report an allegation of abuse within the required two-hour timeframe, which was substantiated during a complaint investigation. Earlier inspections showed a pattern of deficiencies involving resident care issues such as failure to notify families of significant changes, inadequate care planning, medication administration problems, and infection control practices. Complaint investigations frequently substantiated violations related to abuse reporting, misappropriation of property, and failure to properly assess or supervise residents. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility has shown some correction of prior violations, but recent findings indicate ongoing challenges in timely reporting and resident safety oversight.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
9.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
71% worse than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
95% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 71
Capacity: 75
Deficiencies: 0
Oct 20, 2025
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigation #2632376.
Findings
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 Details
Complaint Investigation #2632376 was the basis for the inspection. Violations were substantiated as violations were identified during the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Desell | Administrator | Personnel contacted during the inspection. |
| Connie Vumback | RN | Report submitted by. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 20, 2025
Visit Reason
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.
Findings
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 Details
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.
Deficiencies (1)
| Description |
|---|
| Failure to ensure an allegation of abuse was reported to the Administrator and/or designee within two hours of the incident. |
Report Facts
Complaint number: 2632376
Date of incident: Sep 28, 2025
Date of Facility Reported Incident form: Sep 29, 2025
Plan of correction submission deadline: Nov 24, 2025
Plan of correction monitoring deadline: Dec 1, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Signed the report as representative of the Facility Licensing and Investigations Section |
| NA #1 | Nurse Aide | Witnessed and reported the abuse incident, failed to report allegation within required timeframe |
| Director of Nursing | Director of Nursing | Confirmed facility policy and failure to report allegation within two hours |
Inspection Report
Plan of Correction
Census: 68
Capacity: 75
Deficiencies: 1
Jul 1, 2025
Visit Reason
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.
Findings
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.
Deficiencies (1)
| Description |
|---|
| Violations #1 through #15 identified in the prior inspection |
Report Facts
Violations corrected: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Greg Bush | Director of Nursing Services | Notified via telephone on 2025-07-01 that all violations were corrected |
Inspection Report
Renewal
Census: 71
Capacity: 75
Deficiencies: 0
Apr 22, 2025
Visit Reason
The inspection was conducted as a renewal licensing inspection and included a complaint investigation for complaint numbers 32774 and 43508.
Findings
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 Details
Complaint investigation numbers 32774 and 43508 were part of the inspection process.
Report Facts
Licensed Bed Capacity: 75
Census: 71
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Desell | Administrator | Personnel contacted during inspection |
Inspection Report
Renewal
Census: 71
Capacity: 75
Deficiencies: 0
Apr 22, 2025
Visit Reason
The inspection was conducted as a renewal licensing inspection and included a complaint investigation for complaint numbers 32774 and 43508.
Findings
The report indicates that violations of the General Statutes of Connecticut and/or regulations were not identified at the time of this inspection.
Complaint Details
Complaint investigation numbers 32774 and 43508 were reviewed, but no violations were identified.
Report Facts
Licensed Bed Capacity: 75
Census: 71
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Desell | Personnel contacted during inspection |
Inspection Report
Renewal
Deficiencies: 14
Apr 22, 2025
Visit Reason
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.
Findings
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.
Deficiencies (14)
| Description |
|---|
| Failure to notify Resident #34 of physician-ordered testing and ultrasound results. |
| Failure to notify APRN and family of significant weight loss for Resident #1 and Resident #219. |
| Improper storage of wheelchairs in resident areas instead of a non-resident area. |
| Failure to report allegation of mistreatment and misappropriation of property for Resident #1 to the State Agency. |
| Failure to thoroughly investigate allegation of misappropriation of money for Resident #1. |
| Failure to develop and implement a comprehensive care plan for Resident #1 at risk for falls and ensure two staff members present for direct care of Resident #38. |
| Failure to notify family of Resident #29 regarding significant change in condition. |
| Failure to supervise Resident #15 for wound care and follow physician orders for daily weights. |
| Failure to follow wound consultant recommendations for Resident #17. |
| Failure to provide adequate supervision during mealtimes for Residents #10 and #58 with history of aspiration. |
| Failure to maintain oxygen saturation documentation and properly store oxygen and nebulizer equipment for Residents #1, #2, #15, #219, and #269. |
| Failure to complete required annual performance evaluations for Nurse Aides #1 and #9. |
| Failure to complete pharmacist-identified behavior monitoring for Residents #12 and #269 receiving antipsychotic medication. |
| Failure to follow infection control practices during dressing changes and use of PPE for Resident #17 on Enhanced Barrier Precautions. |
Report Facts
Date of Compliance: Jun 20, 2025
Number of wheelchairs observed: 9
Weight gain: 7.7
Weight loss: 22.7
Missing money amount: 14
Number of residents reviewed for various findings: 1
Number of residents reviewed for medication monitoring: 2
Number of residents reviewed for dining supervision: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judy Birtwistle | Supervising Nurse Consultant | Signed the initial notice letter regarding violations and plan of correction. |
| David Desell | Administrator | Named as responsible for facility compliance and plan of correction oversight. |
| Licensed Practical Nurse #2 | Interviewed regarding notification of Resident #34 ultrasound results and wound care for Resident #15. | |
| Advanced Practice Registered Nurse #2 | Directed to obtain ultrasound for Resident #34 and involved in wound care for Resident #15. | |
| Director of Nursing Services (DNS) | Interviewed multiple times regarding notifications, investigations, and compliance issues. | |
| Licensed Practical Nurse #3 | Interviewed regarding weighing Resident #219 and supervision of Resident #129. | |
| Registered Nurse #4 | Interviewed regarding family notification for Resident #29. | |
| Registered Nurse #5 | Interviewed regarding care plan and wound care for Resident #38 and Resident #15. | |
| Nurse Aide #3 | Observed providing care to Resident #38. | |
| Nurse Aide #5 | Interviewed regarding care for Resident #38. | |
| Licensed Practical Nurse #1 | Interviewed regarding oxygen and nebulizer equipment for Residents #1 and #2. | |
| Pharmacist | Interviewed regarding behavior monitoring recommendations. | |
| Director of Social Services | Involved in investigation of missing money for Resident #1. | |
| Director of Food Services | Interviewed regarding dietary aides and meal tray distribution. | |
| Speech Language Pathologist #1 | Interviewed regarding supervision and feeding guidelines for Resident #10. | |
| Dietician | Interviewed regarding weight loss monitoring for Resident #219. |
Inspection Report
Follow-Up
Census: 70
Capacity: 75
Deficiencies: 2
Apr 2, 2025
Visit Reason
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.
Findings
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.
Deficiencies (2)
| Description |
|---|
| Violation #1 identified in prior inspection |
| Unspecified violation identified in prior inspection |
Report Facts
Licensed Bed Capacity: 75
Census: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregg Busch | DNS | Personnel contacted during inspection and notified of violation corrections |
| Michelle Povilionis | RN NC | Report submitted by |
| Maureen Golas-Markure | Survey Team Leader/Supervisor |
Inspection Report
Follow-Up
Census: 70
Capacity: 75
Deficiencies: 1
Apr 2, 2025
Visit Reason
The inspection was a desk audit and follow-up to verify correction of previous violations.
Findings
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.
Deficiencies (1)
| Description |
|---|
| Violation #1 identified as corrected as of 3/31/2025 |
Report Facts
Licensed Bed Capacity: 75
Census: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregg Busch | DNS | Personnel contacted during inspection |
| Michelle Povilonis | RN NC | Report submitted by |
Inspection Report
Follow-Up
Census: 70
Capacity: 75
Deficiencies: 0
Apr 2, 2025
Visit Reason
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.
Findings
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.
Report Facts
Licensed Bed Capacity: 75
Census: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregg Busch | DNS | Personnel contacted and notified of violation corrections |
| Michelle Povilionis | RN NC | Report submitted by |
| Karen Gworek | RN SNC | Supervisor |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 75
Deficiencies: 0
Feb 24, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint #43083.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Complaint Details
Complaint investigation #43083 was the reason for the visit; violations were substantiated as noted.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Desell | Administrator | Personnel contacted during the inspection. |
| Terri Anderson-Murray | RN | Report submitted by. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 24, 2025
Visit Reason
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.
Findings
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 Details
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.
Deficiencies (1)
| Description |
|---|
| Failure to assess Resident #1's blood sugar when the resident experienced mental status changes, resulting in a critical low blood glucose level not being documented or addressed timely. |
Report Facts
Blood glucose level: 13
Date of compliance: Mar 31, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Author of the notice letter and contact for questions regarding violations. |
| David Desell | Administrator | Administrator of Cheshire House Health Care Facility addressed in the notice. |
| Director of Nursing | Named in the finding for failing to assess Resident #1's blood sugar during condition change. | |
| Licensed Practical Nurse 1 | Interviewed regarding Resident #1's blood sugar checks. |
Inspection Report
Renewal
Census: 75
Capacity: 75
Deficiencies: 0
Jan 15, 2025
Visit Reason
The inspection was a desk audit conducted as part of the renewal licensing process for the facility.
Findings
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.
Report Facts
Licensed Bed Capacity: 75
Census: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Desell | Administrator | Spoke with during inspection; made aware of compliance status |
| Gregory Busch | DNS | Spoke with during inspection; made aware of compliance status |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 75
Deficiencies: 0
Jan 8, 2025
Visit Reason
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.
Findings
Deficiencies and/or violations were cited as a result of this survey.
Complaint Details
Complaint Investigation Survey with ACT Reference Numbers CT #42360 and #42429.
Report Facts
Licensed Bed Capacity: 75
Census: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Desell | Administrator | Personnel contacted during the inspection. |
| Gregory Bush | DNS | Personnel contacted during the inspection. |
| Carla Larocque | RN, NC, Survey Team Leader | Survey Team Leader conducting the inspection. |
| Meg Mckinney | Supervisor | Supervisor overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 4
Nov 20, 2024
Visit Reason
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.
Findings
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.
Complaint Details
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.
Deficiencies (4)
| Description |
|---|
| Missing controlled substance disposition records and blister packs for multiple residents' medications. |
| Failure to address hospital discharge recommendation for treatment order (cryocuff/cold compress) for Resident #1. |
| Failure to ensure correct medication reconciliation and discharge medication administration for Resident #1. |
| Failure to ensure residents had identification bracelets or other visible identification. |
Report Facts
Licensed Beds: 75
Census: 75
Residents without identification bracelet: 52
Residents observed without identification bracelet: 3
Date of Compliance: Dec 30, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Desell | Administrator | Personnel contacted during inspection. |
| Karen Gworek | Supervising Nurse Consultant | Author of the important notice letter regarding the inspection. |
| Terri Anderson-Murray | Report submitted by. | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding missing medication records and hospital discharge orders. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Reported missing controlled substance disposition record during shift-to-shift narcotic count. |
| Registered Nurse #1 | Nursing Supervisor, Registered Nurse (RN) | Interviewed about medication reconciliation and discharge medication review. |
| Registered Nurse #2 | Visiting Nurse, Registered Nurse (RN) | Identified medication discrepancy on discharge medications. |
| Licensed Practical Nurse #3 | Licensed Practical Nurse (LPN) | Provided packet of medications and discharge paperwork to Resident #1. |
Inspection Report
Renewal
Census: 71
Capacity: 75
Deficiencies: 0
Apr 24, 2023
Visit Reason
The inspection was conducted as a renewal licensing inspection for the facility.
Findings
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.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Craig Dumont | Personnel contacted during the inspection | |
| Klespy Bush | Personnel contacted during the inspection |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 75
Deficiencies: 1
Sep 19, 2022
Visit Reason
The inspection visit was conducted as a complaint investigation triggered by Complaint Investigation # CT 00032882 to assess compliance with regulations and statutes.
Findings
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 Details
Complaint Investigation # CT 00032882 was substantiated with violations identified related to resident care and staff conduct.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure the resident choice was honored regarding care provider request, including incidents of delayed assistance and inappropriate staff behavior towards Resident #1. |
Report Facts
Census: 72
Total Capacity: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Meghan Nonamaker | Administrator | Named in relation to the inspection and findings |
| Rosalie Shabet | Director of Nursing | Named in relation to the inspection and findings |
| Maureen Golas-Markure | Supervising Nurse Consultant | Author of the notice regarding the plan of correction |
| Danuta Bruzas | RN NC | Inspection report submitted by |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 75
Deficiencies: 1
Jun 30, 2022
Visit Reason
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.
Findings
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 Details
Complaint Investigation #32465 was substantiated with violations identified related to misappropriation of Resident #1's property by a staff member (NA #4).
Deficiencies (1)
| Description |
|---|
| Failure to ensure Resident #1 was free from misappropriation of property related to a missing phone. |
Report Facts
Licensed Bed Capacity: 75
Census: 72
Residents reviewed: 3
Date of Compliance: Aug 10, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Turner | Administrator | Interviewed regarding the missing phone and investigation. |
| Jacquelyn Harris | FLIS Staff | Report submitted by this staff member. |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 75
Deficiencies: 0
Feb 18, 2022
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigation #CT 31668.
Findings
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 Details
Complaint Investigation #CT 31668 was the basis for the visit. Violations were identified but specific substantiation status is not stated.
Report Facts
Licensed Bed/Bassinet Capacity: 75
Census: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Therese Esperance | RN DNS | Personnel contacted during inspection |
| Marge Simpson | Interim Admin | Personnel contacted during inspection |
| Richard Howe | BSN, RN, NC | Report submitted by |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 75
Deficiencies: 1
Feb 18, 2022
Visit Reason
An unannounced inspection was conducted for the purpose of conducting a complaint investigation for CT 31668.
Findings
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 Details
Complaint investigation #CT 31668 was conducted. Violations were substantiated as violations of Connecticut State Agencies regulations were identified.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure staff provided accompaniment to a physician's office appointment for a resident with cognitive impairment and mobility concerns. |
Report Facts
Licensed Bed Capacity: 75
Census: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Richard Howe | BSN, RNC | Report submitted by and signature on inspection report |
| Therese Esperance | RN DNS | Personnel contacted during inspection |
| Marge Simpson | Interim Admin | Personnel contacted during inspection |
| Maureen Golas Markure | MSN, RN, SNC Supervising Nurse Consultant | Author of the notice letter regarding plan of correction |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 75
Deficiencies: 1
Feb 18, 2022
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff provided accompaniment to a physician's office appointment for a resident with severe cognitive impairment and extensive assistance needs. | SS=D |
Report Facts
Capacity: 75
Census: 62
Deficiency severity: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Nurse for Resident #1 on day of appointment; unaware of appointment and did not send staff to accompany resident |
| LPN #2 | Licensed Practical Nurse | Identified scheduler's responsibility to ensure accompaniment |
| LPN #3 | Licensed Practical Nurse | Stated that cognitively impaired residents are accompanied by staff to appointments |
| Scheduler #1 | Assumed charge nurse would ensure accompaniment for Resident #1 | |
| DON | Director of Nursing | Confirmed facility transportation policy requires accompaniment for residents with cognitive impairment and mobility concerns |
Inspection Report
Plan of Correction
Census: 66
Capacity: 75
Deficiencies: 0
Nov 9, 2021
Visit Reason
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.
Findings
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.
Report Facts
Licensed Bed Capacity: 75
Census: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Turner | Administrator | Notified by telephone on 11/9/21 |
| Peter Kolosky | RN, MSN, NC | Representative of FLIS who conducted the desk audit |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 75
Deficiencies: 5
Oct 7, 2021
Visit Reason
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.
Findings
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.
Complaint Details
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.
Deficiencies (5)
| Description |
|---|
| Failure to ensure a gait belt was utilized when transferring a resident, resulting in a pathological fracture. |
| Failure to ensure appropriate seating of vaccinated and unvaccinated residents in the dining room, risking COVID-19 transmission. |
| Failure to protect residents from mistreatment, including allegations of abuse and neglect. |
| Failure to ensure proper documentation and communication regarding hospice services and unplanned discharges. |
| Failure to maintain and update the facility's water management book and conduct related meetings. |
Report Facts
Licensed Bed Capacity: 75
Census: 63
Inspection Date: Oct 7, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James Murphy | Administrator | Named in relation to the inspection and findings. |
| Karen Gworek | Supervising Nurse Consultant | Signed the violation notice letter. |
| Jeffrey E. Turner | Nursing Home Administrator | Signed the response letter to the violation. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 7, 2021
Visit Reason
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.
Findings
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 Details
Complaint #30839 triggered the investigation. The complaint was substantiated as the facility was found noncompliant with transfer procedures for Resident #1.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure a gait belt was utilized when transferring Resident #1 in accordance with facility policy, leading to improper transfer and resident pain. |
Report Facts
Dates related to resident care and investigation: Sep 8, 2021
Dates related to resident care and investigation: Sep 9, 2021
Dates related to resident care and investigation: Sep 14, 2021
Dates related to plan of correction education: Sep 8, 2021
Dates related to plan of correction education: Sep 10, 2021
Dates related to plan of correction education: Sep 13, 2021
Audit frequency: 4
Audit frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Signed the notice letter regarding the complaint investigation and plan of correction |
| Jeffrey E. Turner | Nursing Home Administrator | Signed the response letter to the violation |
Inspection Report
Census: 66
Capacity: 75
Deficiencies: 1
Sep 7, 2021
Visit Reason
Visit or revisit for the purpose of a Federal Comparative Survey conducted on 8/24/21.
Findings
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.
Deficiencies (1)
| Description |
|---|
| Deficiencies F 600 and F 609 were corrected and put back into compliance. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ellen Valentin | RN Nurse Consultant | Report submitted by and nurse consultant involved in review. |
| James Murphy | Administrator | Personnel contacted during inspection. |
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 24, 2021
Visit Reason
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.
Findings
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.
Deficiencies (1)
| Description |
|---|
| Failure to ensure appropriate seating of vaccinated and unvaccinated residents and failure to ensure weekly COVID-19 testing of unvaccinated staff members. |
Report Facts
Date of inspection: Aug 24, 2021
Compliance date: Sep 24, 2021
Social distancing requirement: 6
Weekly testing frequency: 1
Audit frequency: 4
Audit frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Author of the notice letter |
| James Murphy | Administrator | Facility administrator addressed in the letter |
| LPN #2 | Licensed Practical Nurse | Identified in findings related to vaccination knowledge and resident seating |
| Director of Nursing | Interviewed regarding vaccination education and seating practices | |
| Nurse aide #2 | Nurse Aide | Interviewed regarding dining room seating and resident placement |
Inspection Report
Annual Inspection
Deficiencies: 10
May 27, 2021
Visit Reason
Unannounced visits were made to Cheshire House Health Care Facility to conduct a recertification survey and multiple complaint investigations.
Findings
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.
Complaint Details
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.
Deficiencies (10)
| Description |
|---|
| Failure to initiate interventions in response to Resident Council concerns about cold food. |
| Failure to ensure completion of Advanced Directive forms for residents. |
| Failure to protect residents from mistreatment and abuse. |
| Failure to report allegations of mistreatment in a timely manner. |
| Failure to notify the Office of the State Long-Term Care Ombudsman of resident transfers. |
| Failure to notify residents or representatives of bed-hold and reserve bed payment policy before hospital transfer. |
| Failure to ensure neurological checks were completed after falls. |
| Failure to discard expired food items and ensure food items were dated or labeled. |
| Failure to ensure Hospice agency provided documentation and progress notes from visits. |
| Failure to provide documentation of annual water management book update and meetings of the Water Management Committee. |
Report Facts
Complaint numbers: 5
Residents reviewed for Advance Directives: 3
Residents reviewed for abuse: 2
Residents reviewed for notice requirements: 1
Residents reviewed for accidents: 3
Residents reviewed for dietary services: 1
Residents reviewed for hospice services: 1
Residents reviewed for infection control: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judy Birtwistle | Supervising Nurse Consultant | Signed the notice letter and referenced as contact for questions regarding violations. |
| James J. Murphy | Administrator | Named as facility administrator and submitted the plan of correction. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding Advance Directive compliance and resident care. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding resident care and medication administration. |
| Nursing Assistant #2 | Nursing Assistant | Interviewed regarding resident care and response to call bell. |
| Administrator (previous) | Referenced regarding purchase orders for insulated plate covers. | |
| Dietary Supervisor | Interviewed regarding food service and dietary violations. | |
| Assistant Director of Nurses (acting DNS) | Assistant Director of Nurses | Interviewed regarding abuse allegations and Advance Directive compliance. |
| Social Worker #1 | Social Worker | Interviewed regarding notification of Ombudsman for resident transfers. |
| RN #1 | Registered Nurse | Interviewed regarding Advance Directive compliance and abuse allegations. |
| RN #2 | Registered Nurse | Interviewed regarding abuse allegations and reporting. |
| Nursing Assistant #7 | Nursing Assistant | Involved in abuse allegations and terminated from position. |
| Nursing Assistant #4 | Nursing Assistant | Involved in abuse allegations and interviewed. |
| Nursing Assistant #5 | Nursing Assistant | Involved in abuse allegations and interviewed. |
| Hospice Nurse Coordinator | Interviewed regarding hospice documentation. | |
| Admissions Coordinator #1 | Interviewed regarding bed hold policy notification. |
Inspection Report
Monitoring
Deficiencies: 1
Jul 24, 2020
Visit Reason
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.
Findings
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 Details
Complaint #28016. The visit was complaint-related as indicated by the complaint number and investigation purpose. Substantiation status is not stated.
Deficiencies (1)
| Description |
|---|
| Failure to revise the care plan to address the need to offload Resident #1's heels to prevent deep tissue injury or pressure ulcer. |
Report Facts
Braden scale score: 14
Measurement of deep tissue injury: 3
Measurement of deep tissue injury: 4
Dates of physician orders: 3/25/20 and 5/8/20
Date of Braden scale assessment: 3/7/20
Date of Minimum Data Set assessment: 3/9/20
Date of Resident Care Plan: 3/18/20
Date of nurses progress note: 5/15/20
Date of hospital progress note: 5/15/20
Date of last weekly skin check documented: 5/14/20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Author of the inspection report and contact for questions regarding violations. |
| Nicole Lewis | Administrator | Facility administrator addressed in the report. |
| Director of Nursing | Interviewed regarding failure to address offloading heels in care plan. | |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about resident care and COVID-19 prevention guidelines. |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 75
Deficiencies: 1
Jul 24, 2020
Visit Reason
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.
Findings
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 Details
Complaint Investigation #28016 was substantiated with a deficiency identified related to pressure ulcer prevention.
Deficiencies (1)
| Description |
|---|
| The facility failed to implement interventions to prevent a pressure ulceration to a Resident's heel. |
Report Facts
Licensed Beds: 75
Census: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kenitra Sherman | DNS | Personnel contacted during the inspection. |
| Nicole Lewis | Administrator | Personnel contacted during the inspection. |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 75
Deficiencies: 1
Jul 24, 2020
Visit Reason
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.
Findings
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.
Complaint Details
The visit was complaint-related under ACTS Reference Number CT #00028016. A deficiency was cited related to pressure ulcer prevention and care.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to revise the care plan to address the need to offload heels to prevent pressure ulcers for Resident #1. | SS=D |
Report Facts
Capacity: 75
Census: 61
Braden scale score: 14
Pressure ulcer size: 3
Pressure ulcer size: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Provided information about Resident #1's condition and care during interview |
| Director of Nursing | DON | Interviewed regarding care plan and documentation deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 24, 2020
Visit Reason
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.
Findings
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.
Deficiencies (1)
| Description |
|---|
| Failure to revise the care plan to address the need to offload the resident's heels to prevent pressure ulcers. |
Report Facts
Dates related to care and injury: May 15, 2020
Dates related to assessments: Mar 7, 2020
Dates related to assessments: Mar 9, 2020
Dates related to care plan: Mar 18, 2020
Dates related to treatment administration record: May 14, 2020
Dates related to progress notes: May 15, 2020
Dates related to interviews: Jul 24, 2020
Audit frequency: 4
Audit frequency: 2
Plan monitoring date: Sep 4, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Identified increased time in bed and poor fluid intake for Resident #1. |
| Director of Nursing | Director of Nursing | Interviewed regarding failure to address preventative measures for pressure reduction. |
Inspection Report
Abbreviated Survey
Census: 52
Capacity: 75
Deficiencies: 0
Jul 15, 2020
Visit Reason
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.
Findings
No deficiencies were cited as a result of this COVID-19 Focused Infection Control Survey.
Inspection Report
Abbreviated Survey
Census: 48
Capacity: 75
Deficiencies: 1
Jun 24, 2020
Visit Reason
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.
Findings
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.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a contract for removal and disposal of regulated biomedical waste was in place, leading to accumulation of biomedical waste for several months. | SS=E |
Report Facts
Capacity: 75
Census: 48
Full sharp collection containers: 20
Cardboard boxes labeled infectious waste: 3
Large plastic bins overflowing with biomedical waste bags: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding biomedical waste accumulation and contract status | |
| Director of Nursing | Acting DON until three weeks prior; notified Administrator of biomedical waste issues | |
| Physical Plant Director | Interviewed about biomedical waste accumulation and contract issues | |
| Chief Operating Officer | Interviewed about contract termination and new biomedical waste contract | |
| Infection Control Nurse | Acting DON until three weeks prior; notified Administrator of biomedical waste issues |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jun 19, 2020
Visit Reason
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.
Findings
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.
Deficiencies (1)
| Description |
|---|
| Failure to ensure a contract for removal and disposal of regulated biomedical waste was in place, leading to accumulation of biomedical waste for several months. |
Report Facts
Number of large cardboard boxes labeled infectious waste: 3
Number of large plastic bins overflowing with biomedical waste bags: 4
Number of biomedical waste bags on the floor: 3
Number of full sharp collection containers scattered on the floor: 20
Time since last biomedical waste removal: 12
Time as Director of Nursing for current DON: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Lewis | Administrator | Named in relation to biomedical waste contract and removal issues |
| Karen Gworek | Supervising Nurse Consultant | Author of the notice letter |
Inspection Report
Routine
Deficiencies: 1
Jun 19, 2020
Visit Reason
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.
Findings
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.
Deficiencies (1)
| Description |
|---|
| Excessive accumulation of biomedical waste in the biomedical waste storage room with multiple full containers and bags on the floor due to non-payment and contract issues with the waste removal company. |
Report Facts
Date of visits: 2
Number of large cardboard boxes: 3
Number of large plastic bins overflowing: 4
Number of biomedical waste bags on floor: 3
Number of full sharp collection containers: 20
Duration of biomedical waste accumulation: 6
Correction date: Jul 16, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Author of the notice letter |
| Nicole Lewis | Administrator | Administrator of Cheshire House Health Care Facility involved in inspection |
| Karen Gworek | Supervising Nurse Consultant | Contact for questions regarding violations |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 75
Deficiencies: 0
Jun 1, 2020
Visit Reason
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.
Findings
No deficiencies were cited as a result of this survey.
Complaint Details
Complaint Investigation Survey, ACTS Reference Number CT00027726. No deficiencies were cited.
Report Facts
Capacity: 75
Census: 45
Inspection Report
Routine
Census: 42
Capacity: 75
Deficiencies: 0
May 29, 2020
Visit Reason
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.
Findings
No deficiencies were cited as a result of this COVID-19 Focused Survey.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Apr 21, 2020
Visit Reason
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.
Findings
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.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to timely institute transmission-based precautions and isolate/cohort three residents with symptoms of COVID-19 according to CDC guidelines. | SS=D |
Report Facts
Residents with symptoms of COVID-19 not timely isolated: 3
Resident #7 temperatures: 99.4
Resident #7 temperatures: 100.6
Resident #10 temperature: 101.1
Resident #15 temperature: 102.3
Resident #15 SPO2: 86
Isolation precaution completion date: 2020
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 21, 2020
Visit Reason
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.
Findings
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.
Complaint Details
The visit was complaint-related, focusing on infection control practices regarding COVID-19. The report does not explicitly state substantiation status.
Deficiencies (1)
| Description |
|---|
| Failure to timely institute transmission based precautions and isolate/cohort three residents with COVID-19 symptoms according to CDC guidelines. |
Report Facts
Residents with COVID-19 symptoms: 3
Residents reviewed with symptoms: 9
Dates of nursing observations: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa A. DiLorenzo | Supervising Nurse Consultant | Author of the notice and contact for questions regarding violations. |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 75
Deficiencies: 8
Mar 11, 2019
Visit Reason
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.
Findings
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 Details
Complaint investigation based on complaints #23874, 24284, and 24409. Violations were substantiated as noted in the attached violation letter dated 3/21/19.
Deficiencies (8)
| Description |
|---|
| Failure to ensure neurological assessments were documented in the clinical record for Resident #2 with neurological trauma diagnosis. |
| Failure to maintain sufficient nursing staff to provide nursing related care and services for residents. |
| Failure to ensure expired medication and biologicals were discarded in a timely manner. |
| Failure to maintain sanitizing solution at required levels in dietary services. |
| Failure to ensure timely assistance with meals for residents. |
| Failure to ensure accurate reflection of residents' Advanced Directives in physician orders and care plans. |
| Failure to implement interventions for physical therapy evaluation when resident declined in ambulation. |
| Failure to ensure bed hold notice policy was followed and documented properly. |
Report Facts
Licensed Bed Capacity: 75
Census: 67
Inspection Dates: Inspection conducted on March 11, 12, and 13, 2019.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Courtney Young | Administrator | Named as personnel contacted during the inspection and in correspondence. |
| Winsome Huclulok | Director of Nursing | Named as personnel contacted during the inspection. |
| Karen Gworek | Supervising Nurse Consultant | Signed the complaint investigation report. |
Inspection Report
Renewal
Census: 69
Capacity: 75
Deficiencies: 1
Mar 7, 2019
Visit Reason
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.
Findings
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.
Deficiencies (1)
| Description |
|---|
| Violations of the General Statutes of Connecticut and/or regulations were identified at the time of inspection, as noted in the attached violation letter dated 4-2-19. |
Report Facts
Licensed Bed Capacity: 75
Census: 69
Inspection Dates: 4
Plan of Correction Submission Deadline: Apr 16, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Courtney Young | Administrator | Administrator contacted during inspection and named in plan of correction letter |
| Connie Greene | Supervising Nurse Consultant | Signed the letter regarding violations and plan of correction |
| Millicent P. Reynolds | RN | Named in desk audit report regarding correction implementation |
Inspection Report
Annual Inspection
Deficiencies: 3
Mar 4, 2019
Visit Reason
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.
Findings
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.
Deficiencies (3)
| Description |
|---|
| Failure to notify resident representative when Resident #17 developed a right heel blister. |
| Failure to submit residents' MDS assessments within 14 days to the state agency as required. |
| Failure to implement offloading prior to the development of a pressure ulcer on Resident #17's heel. |
Report Facts
Dates of inspection visits: 4
Date of admission for Resident #17: Dec 18, 2018
Braden Scale score: 14
Size of right heel blister: 4.5
Wound measurement: 4.1
Dates of MDS assessments missing submission: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Connie Greene | Supervising Nurse Consultant | Signed letter regarding plan of correction and violations |
| Courtney Young | Administrator | Named as recipient of the inspection report and plan of correction |
Report
Oct 20, 2025
File
complaint-inspection_2025-10-20.pdf
Report
Apr 22, 2025
File
complaint-inspection_2025-04-22.pdf
Report
Apr 22, 2025
File
health-inspection_2025-04-22.pdf
Report
Feb 24, 2025
File
complaint-inspection_2025-02-24.pdf
Report
Feb 10, 2025
File
complaint-inspection_2025-02-10.pdf
Report
Jan 9, 2025
File
complaint-inspection_2025-01-09.pdf
Report
Nov 20, 2024
File
complaint-inspection_2024-11-20.pdf
Report
Aug 1, 2023
File
complaint-inspection_2023-08-01.pdf
Report
Apr 28, 2023
File
health-inspection_2023-04-28.pdf
Report
May 27, 2021
File
health-inspection_2021-05-27.pdf
Loading inspection reports...
