Cheshire Home

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide a homelike environment for residents in 1 of 12 resident rooms observed and was evidenced by the following. On 1/5/26 at 6:50 PM, the surveyor knocked on door for room [ROOM NUMBER] and received permission from Resident #7 to enter the room. The resident pointed out the ceiling in the center of room and stated, this does not look nice. Resident #7 stated being upset that the ceiling gridwork and ventilation cover were soiled and in need of cleaning and maybe replacement. The surveyor observed a reddish brown colored crusted substance on the ceiling gridwork slats and black colored stains on HVAC (heating, ventilation and air conditioning) diffuser on the ceiling in the center of the resident's room. [...]

Inspectors wroteBased on interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to follow their abuse policy to ensure criminal background checks were completed prior to hire for 2 out of 47 newly hired staff (Staff #45 and #47). This deficient practice was evidenced by the following: The surveyors reviewed 47 new employee files for criminal background and reference checks which revealed the following: A review of Staff #45's file, a driver with a date of hire (DOH) of 11/25/24, showed a background screening report (BSR) dated 12/9/24 and there were no references found in their file. The BSR was completed after Staff #45's DOH. A review of Staff #47's file, a Licensed Practical Nurse with a DOH of 3/25/25, showed a BSR dated 3/26/25. The BSR was completed after Staff #47's DOH. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to develop a comprehensive, person-centered care plan (CP) for a resident on antidepressant medication. This deficient practice was identified in 1 (one) of the 13 residents (Resident#5) reviewed for CP.This deficient practice was evidenced by the following: On 1/6/26 at 11:30 AM, the surveyor observed Resident #5 out of bed to the motorized wheelchair and able to answer questions appropriately. On 1/6/26 at 11:50 AM, the surveyor reviewed the electronic Health Record (eHR)/ hybrid medical record (paper and electronic) of Resident #5, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #5 was admitted with diagnoses that included but were not limited to paraplegia (paralysis that affects the lower part of the body). [...]

Inspectors wroteBased on observations, interviews, record review and review of other pertinent facility provided documentation, the facility failed to ensure that physician ordered weekly skin assessments were conducted at scheduled intervals for 2 of 4 residents (Residents #3 and #33), reviewed for pressure ulcer prevention and was evidenced by the following: 1. A review of Resident #3's admission record reflected Resident #3 was admitted to the facility with diagnoses including but not limited to quadriplegia (paralysis of all four extremities), stage III pressure ulcer in area of right buttock and chronic osteomyelitis (an infection of the bone). A review of the Quarterly Minimum Data Set (MDS), an assessment tool dated 10/29/25, reflected the resident had a Brief Interview Mental Status (BIMS) score of 15 of 15 which indicated that there were no deficits in cognition. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure that the resident's call light was readily accessible within reach. The deficient practice was identified for one (1) of one (1) resident, Resident #1, reviewed for accommodation of needs. This deficient practice was evidenced by the following: On 9/03/2024 at 9:20 AM, the surveyor observed Resident #1 sitting in their wheelchair (w/c) beside the bed in their room. The resident was alert, awake, and verbally responsive with slurred speech. The surveyor observed the resident's call light was resting on the opposite side of the bed against the wall and the resident was unable to reach it. On 9/04/2024 at 9:41 AM, the surveyor observed the resident sitting in their w/c beside the bed in their room. [...]

Inspectors wroteBased on interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure reference checks were completed for two (2) out of six (6) newly hired staff (Staff #1 and #2) prior to their start date of employment. This deficient practice was evidenced by the following: The surveyor reviewed six randomly selected new employee files. The review for reference checks for two of the six new employees revealed the following: -Staff #1's (S#1's) file, a Licensed Practical Nurse (LPN) who was hired on 02/25/24, showed there were no reference checks in their file. -S#2, a Registered Nurse (RN) who was hired on 4/06/24, showed there were no reference checks in their file. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to provide care and services consistent with professional standards of practice for a resident with pressure ulcers. This deficient practice was identified in two (2) of two (2) residents (Resident #8 and #9), reviewed for pressure ulcer care and prevention. The deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to provide care and services in a manner consistent with standards of practice for appropriate storage of urinary drainage bags for one (1) of one (1) resident reviewed for external urinary catheter care (Resident #15). The deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a.) ensure nebulizer setup and masks were changed as per physician orders. b.) change suction setup tubing for the tracheostomy resident. This deficient practice was identified for one (1) of two (2) residents (Residents #11) reviewed for respiratory care according to the standard of clinical practice, and the facility's policy and procedure. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to ensure the daily report of licensed nurses, certified nursing assistant staffing, and the resident census was posted at the beginning of the current shift for two (2) of four (4) days during the survey. This deficient practice was evidenced by the following: On 9/03/24 at 7:40 AM, upon entry to the facility, the surveyor observed a Nursing Home Resident Care Staffing Report (NHRCSR) posted at the front desk by the main entrance. The NHRCSR posted was dated 9/02/24, for the [8 AM to 4 PM] day shift. There was no NHRCSR for 9/03/24 posted. On 9/05/24 at 8:35 AM, the surveyor observed a NHRSCR posted at the front desk by the main entrance. The NHRCSR posted was dated 9/04/24 for the day shift. There was no NHRCSR for 9/05/24 posted. [...]

Inspectors wroteBased on interviews, record review, and a review of pertinent facility documents, it was determined that the facility failed to identify the irregularity with regard to the physician's order for as needed pain medications for one (1) of five (5) residents, (Resident #21) reviewed for unnecessary medications in accordance with facility's practice and policy. This deficient practice was evidenced by the following: On 9/03/24 at 10:42 AM, the surveyor observed Resident #21 with limitation to the right hand and could use the electric wheelchair with no problem. The resident had a splint on their right hand. On that same date and time, the resident stated that he/she was currently on pain management and included in their pain medications (meds) were as needed (PRN) Oxycodone to be given with PRN Tylenol for pain level of 7-10. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) psychiatric recommendations from 7/24/24 for laboratory (lab(s)) and b.) routine lab orders for January and June 2024 were followed and obtained in a timely manner. The deficient practice was identified for one (1) of five (5) residents reviewed for unnecessary medications (Resident #21), and was evidenced by the following: On 9/03/24 at 9:12 AM, the surveyor observed Resident # 21's room was closed. The Staff stated that the resident was about to get showered, and the surveyor had to return at a later time. The surveyor reviewed Resident #21's hybrid (a combination of paper-based and electronic medical records that primarily involves tracking and storing a patient's health records in several formats and places) medical records. [...]

Inspectors wroteBased on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene, use of personal protective equipment (PPE), and disinfect equipment practices for one (1) of four (4) staff (Physical Therapist, Dietary Staff, and two nurses) and b.) follow appropriate infection control practices prevent the potential spread of infection for two (2) of two (2) rooms observed during laundry area tour in accordance with the Center for Disease Control and Prevention (CDC) guidelines and facility's policy. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24 revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: [...]

Inspectors wroteBased on document review and interview, the facility failed to ensure there was a Registered Nurse (RN) on duty for eight continuous hours per day. This failure had the potential to affect the residents' assessments, residents' care and treatments for all 32 residents in the facility.

Inspectors wroteBased on review of facility policy, record review, and staff interviews, the facility failed to ensure medication was consistently available for one (Resident (R)24 of 17 residents reviewed in the sample. Pain medication was not administered to the resident due to lack of availability of the medications in the facility.