Inspection Reports for
Cheshire House

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.

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.

The complaint investigation involved one sampled resident (Resident #1) with dementia and behavioral disturbances. The allegation was made by Nurse Aide #1 who witnessed Nurse Aide #2 providing care against the resident's refusal. The allegation was reported the day after the incident, which violated the facility's policy requiring immediate reporting within two hours. The Director of Nursing confirmed the policy and the failure to comply.

The facility failed to ensure that an allegation of abuse was reported to the Administrator and/or designee within two hours of the incident as required by facility policy. The allegation involved a nurse aide continuing to provide care to a resident who refused, which was deemed abusive by a witness nurse aide.

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 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 facility failed to provide adequate supervision and proper communication of feeding and supervision guidelines for residents with aspiration risks during mealtime. Multiple residents were observed eating unsupervised despite physician orders and care plans requiring direct or intermittent supervision. There were also communication failures between nursing and dietary staff regarding residents' feeding needs and supervision levels.

The facility was found deficient in multiple areas including failure to inform residents of test results, failure to notify physicians and families of significant weight changes, improper storage of wheelchairs, failure to report and investigate alleged misappropriation of resident property, incomplete care plans for fall risk and direct care assistance, failure to document family notification of change in condition, inadequate supervision during meals for residents with aspiration risk, improper wound care technique and infection control, failure to date oxygen tubing and properly store respiratory equipment, missing annual nurse aide performance evaluations, and failure to monitor target behaviors for residents on antipsychotic medications.

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.

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.

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 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.

The facility failed to assess Resident #1's blood sugar at the time of a change in mental status, despite physician orders and care plans indicating the need for monitoring. The resident was later found to have a critically low blood glucose level upon arrival at the Emergency Department.

The complaint investigation found that the family requested a room change on 1/16/2025 due to the roommate's disruptive behavior at night. The request was not addressed, and staff including the Director of Nursing were unaware of the request until the day of discharge. The complaint was substantiated with findings of failure to act on the request.

The facility failed to follow up on a room change request made by the family of Resident #1 on 1/16/2025, despite the resident's complaints of anxiety and inability to sleep due to the roommate. Interviews revealed staff were unaware or unable to explain why the request was not addressed prior to the resident's discharge on 1/27/2025.

The facility failed to adequately address resident grievances regarding lengthy call light response times, failed to notify the physician timely of a resident's change in condition, and failed to provide adequate supervision to prevent sexual abuse between residents. Staff education and audits were initiated but documentation was lacking. The incidents involved minimal harm and affected a few residents.

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 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 complaint investigation was triggered by reports of missing controlled medications and disposition records. The Department of Consumer Protection, Drug Enforcement Division (DCP) was notified and oversaw the investigation. A Licensed Practical Nurse was identified as removing controlled medications and was terminated.

The facility failed to protect residents from wrongful use of their controlled medications, resulting in missing narcotics and controlled substance disposition records for multiple residents. The facility also failed to implement hospital discharge orders for treatment, sent incorrect medications with a discharged resident, and did not ensure residents wore identification bracelets as required.

The complaint involved allegations of verbal abuse by nurse aides toward Resident #1 and Resident #3. The facility failed to ensure respectful treatment and failed to timely report the abuse incident to the Administrator and Director of Nursing. Resident #1 denied one comment but reported another nurse aide's verbal abuse. The nurse aide who witnessed the abuse reported it to the charge nurse immediately, but the Director of Nursing was only informed the next day.

The facility failed to ensure residents were treated with dignity and respect, as evidenced by verbal abuse incidents involving nurse aides. Additionally, the facility failed to timely report the suspected abuse to the Administrator and Director of Nursing as required by policy.

The facility was found deficient in multiple areas including improper storage of bedpans, failure to resolve grievances regarding staff ID badges and resident care, misappropriation of resident property, failure to report abuse and neglect allegations, incomplete investigations of mistreatment allegations, failure to notify the ombudsman of resident transfers, inaccurate MDS assessments, medication order transcription errors, failure to provide scheduled showers, missed medical appointments, improper pressure ulcer care, failure to conduct UTI monitoring, failure to conduct monthly weights, failure to obtain daily weights for dialysis patients, lack of annual nurse aide evaluations, missing signed advanced directives, improper hand hygiene, and failure to offer COVID-19 booster vaccinations upon admission.

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

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

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

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.

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.

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 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.

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

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.

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.

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.

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.

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 facility was found deficient in multiple areas including failure to ensure residents were treated with dignity and respect, failure to implement interventions for resident concerns, incomplete advance directive documentation, failure to protect residents from abuse and timely report allegations, failure to notify the Ombudsman of unplanned hospital discharges, failure to complete neurological checks after falls, failure to discard expired or unlabeled food items, failure to document hospice visits, and failure to maintain infection control documentation.

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

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

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.

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

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.

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.

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.

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.

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.

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.

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

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

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.

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.

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.