Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Civita Care Center At Cheshire during CMS and state inspections, most recent first.
A dependent, cognitively impaired resident with multiple psychiatric and physical diagnoses, including poor memory and total dependence for all ADLs, was found by a family member lying flat in bed completely undressed and uncovered. During the morning shift, a NA providing care left the room to obtain cream, closing the door and pulling the curtain but leaving the resident without any covering. The RN supervisor learned of the incident from the family member and was told by the NA that she had left to get cream but denied leaving the resident uncovered. The DON later confirmed that the incident was not reported to her at the time and that leaving the resident exposed violated the facility’s Resident Rights policy requiring treatment with dignity and respect.
A dependent, cognitively impaired and fully incontinent resident with multiple diagnoses, including a pressure ulcer, was care planned for toileting and incontinent care at least every two hours and at specific times throughout the day. A family member later found the resident saturated in urine and feces and reported this to an LPN, who learned from a NA that incontinent care had not been provided since the beginning of the shift, nearly five hours earlier, despite facility policy and the resident’s care plan requiring regular check-and-change. The DON reported she had not been informed of the incident and stated that incontinent care or monitoring should occur multiple times each shift, with the charge nurse responsible for ensuring NAs follow the incontinence policy.
A resident dependent on staff for transfers and requiring a mechanical lift with two-person assistance was transferred by a single nurse aide, contrary to care plan and facility policy. Following this unsupervised transfer, the resident sustained multiple skin tears, bruising, and an acute hip fracture. The incident was confirmed through clinical records and staff interviews.
A resident with an amputation, impaired cognition, and type 2 diabetes requiring insulin and extensive assistance with ADLs was admitted without a baseline care plan addressing their needs for ADL support and diabetes management. Despite multiple assessments and physician orders detailing these requirements, the baseline care plan failed to include them, as confirmed by staff interviews and record review.
A resident with diabetes experienced multiple episodes of low blood sugar, during which nursing staff administered treatments and performed follow-up checks. However, the clinical record did not consistently document these interventions, follow-up blood glucose readings, or provider notifications as required by facility policy. Staff interviews confirmed that some actions were performed but not recorded, resulting in incomplete and inaccurate medical records.
The facility did not ensure dietary staff consistently monitored and documented food temperatures before meal service, as required by policy. Several Service Line Checklists lacked temperature records, and the Dietary Manager was aware but had not addressed the issue. The Administrator was also unaware of the missing documentation.
A resident with hemiplegia following a stroke experienced a violation of their rights when a nurse aide made a disrespectful comment regarding food preferences. The aide suggested the resident eat the meal tray before cookies, which was inappropriate and disregarded the resident's right to choose. The facility's policy requires treating residents with respect and dignity, which was not followed in this case.
A facility failed to hold interdisciplinary care conferences for a resident, missing six quarterly meetings over a year and a half. The resident, with intact cognition and independence in some activities, expressed a desire to attend these meetings. Staff interviews revealed systemic issues, with the MDS coordinator unable to attend due to time constraints and the social worker conducting one-on-one meetings instead of interdisciplinary conferences, contrary to facility policy.
A resident's representative was not informed of their rights upon admission to the facility. Despite attempts by the Admissions Director to contact the representative, the necessary admission documents remained unsigned and undated. The DNS confirmed that the admitting nurse should have ensured the completion of the paperwork, but this was not done, leading to a deficiency.
The facility failed to obtain timely physician orders for advance directives for three residents. One resident's DNR status was not documented in a physician's order until 11 months after admission. Another resident's Full Code status was not reflected in the care plan or physician's orders until after surveyor inquiry. A third resident's advance directives were not reviewed upon admission, and the admitting nurse did not complete the necessary paperwork within the expected timeframe.
A resident with severe cognitive impairment and dependent on tube feeding was transferred to the hospital twice due to gastrostomy tube dislodgement. The facility failed to notify the resident's representative of these transfers, leading to distress when the representative was informed by hospital staff instead. The RN involved believed he had contacted the representative but lacked documentation to confirm this.
The facility failed to update care plans for two residents after multiple feeding tube dislodgements. One resident with a GJ tube and another with a gastrostomy tube experienced dislodgements, but their care plans were not revised with new interventions. The DNS acknowledged the oversight, and the facility's policy requires care plan updates after significant changes, which were not followed.
A resident with hemiplegia following a stroke did not receive necessary meal setup assistance as per their care plan. The resident, who required substantial assistance, reported feeling intimidated and reluctant to ask for help when a nurse aide occasionally failed to set up their food tray. The aide admitted to providing assistance only if remembered and when requested, contrary to facility policy requiring staff to offer help with meals to all residents.
Two residents in an LTC facility experienced unwitnessed falls and a head strike, but the required neurological assessments were not completed. One resident had an initial check documented, but no further assessments were recorded. Another resident had multiple incidents where assessments were incomplete or not conducted, and refusals were not properly managed. The DNS and staff interviews revealed a failure to adhere to the facility's neurological assessment policy.
A resident with severe cognitive impairment and high risk for pressure ulcers did not receive weekly skin assessments as ordered, leading to the development of a stage 3 pressure ulcer. The facility failed to complete these assessments on several occasions, as confirmed by staff interviews and documentation review.
A facility failed to provide adequate supervision and assistive devices, resulting in multiple incidents. A resident with brain damage eloped despite being low risk, and another with dementia left the facility unnoticed. A resident with obesity was injured during a hoyer lift transfer, and another fell during therapy due to poor wheelchair positioning. Additionally, a resident fell due to a broken wheelchair seat belt.
A resident with a GJ tube experienced repeated dislodgement due to the facility's failure to ensure the use of an abdominal binder and inadequate education of the resident's spouse. Despite the care plan's recommendation, the binder was not consistently used, and the spouse, who faced a language barrier, removed it. The facility did not utilize available resources to communicate the importance of the intervention, leading to repeated hospital visits for tube replacement.
The facility failed to serve meals at appetizing temperatures, as residents frequently complained about cold food. The FSD acknowledged these complaints and ongoing efforts to deliver hot food timely. A temperature check revealed several hot food items were served below the expected 140°F, with some as low as 106.7°F. The DNS was aware of these complaints and expected adequate food temperatures. The facility's policy required maintaining proper temperatures to prevent foodborne illness.
The facility failed to follow infection control policies, including hand hygiene after glove removal and proper medication dispensing. An LPN did not wash hands after glove removal before touching items near a resident, and another LPN touched medication with her hands instead of dispensing it directly into a cup. Additionally, the facility missed several months of required environmental infection control rounds.
The facility failed to offer and document influenza and pneumococcal vaccinations for two residents, including education on benefits and side effects. One resident with pneumonia and stroke, and another with chronic obstructive pulmonary disease, had no records of being offered or receiving the vaccines. The Infection Preventionist confirmed the lack of documentation and contact with representatives, contrary to facility policy.
The facility failed to offer COVID-19 vaccinations and track the vaccination status for two residents. One resident with severe cognitive impairment was not offered a booster dose despite being eligible, and another resident's vaccination status was not documented upon admission. The Infection Preventionist did not follow up on these cases, leading to a deficiency in the facility's vaccination protocol.
The facility failed to submit the 4th quarter PBJ report on time due to a delay caused by corporate staff instructions to hold the report for review. The report was submitted after the deadline, and no policy for PBJ submission was provided.
A resident's $2,000 in cash was misappropriated due to the facility's failure to secure the safe where the money was stored. The safe had been left unlocked for at least two years, and multiple staff members had access to the business office key, compromising the security of residents' belongings.
Resident Left Uncovered and Exposed During Personal Care
Penalty
Summary
A resident with schizophrenia, depression, anxiety, adult failure to thrive, muscle weakness, poor memory recall, and total dependence on staff for all ADLs, including bed mobility, transfers, bathing, dressing, personal hygiene, eating, and toileting, was found undressed and fully exposed in bed. The resident’s care plan directed staff to allow extra time to complete tasks, encourage the resident to make choices as able, praise efforts, and report changes in functional ability to the physician. A family member reported entering the resident’s room and finding the resident completely undressed, lying flat in bed with nothing covering the body. The 7AM–3PM nurse aide assigned to the resident stated that while providing care she left the room to obtain cream, pulling the curtain and closing the door but leaving the resident on the bed without any covering. The 7AM–3PM RN supervisor reported that the family member informed her that the resident had been found exposed, and that the nurse aide told her she had left the room to get cream but denied leaving the resident uncovered. The DON stated it had not been reported to her that the resident was found exposed, and confirmed that facility policy requires all residents to be treated with dignity and respect. The DON acknowledged that the resident was not treated with dignity when left in bed without being covered and that the nurse aide made an error in judgment. The facility’s Resident Rights policy states that residents have the right to a dignified existence and to be treated with respect, kindness, and dignity.
Failure to Provide Timely Incontinent Care per Care Plan and Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide incontinent care according to the resident’s care plan and facility policy for one dependent resident. The resident had diagnoses including schizophrenia, depression, anxiety, adult failure to thrive, and muscle weakness, and was care planned on 1/21/26 as needing assistance with all ADLs due to cognitive and physical deficits, having urinary incontinence, and a pressure ulcer. The care plan directed staff to check the resident for incontinence every two hours and as needed, assist with toileting, and provide resident-specific toileting upon rising, after meals, at bedtime, and at five specified times each day (8:00 AM, 10:30 AM, 2:00 PM, 6:30 PM, and 9:00 PM). A Significant Change in Condition MDS assessment documented that the resident had poor memory recall, was always incontinent of bowel and bladder, and was dependent for all ADLs including bed mobility, transfers, bathing, dressing, personal hygiene, eating, and toileting hygiene. On 2/21/26 at approximately 10:30 AM, a family member arrived and found the resident saturated in urine and feces and reported this to the charge nurse (LPN). During interview, the 7AM–3PM NA stated incontinent care should be provided every two hours and as needed for incontinent residents but could not recall specific details of the incident. The 7AM–3PM charge nurse later reported that, on the date of the incident, the family member told her the resident was soaked in urine; when the LPN asked the NA when care was last provided, the NA stated she had been busy and had not provided incontinent care since first rounds at the beginning of the shift at 7:00 AM, nearly five hours earlier. The DON stated she was not informed of the concern and explained that incontinent care or monitoring should occur during first rounds and at least four times per shift, including at the end of each shift, and that it is the charge nurse’s responsibility to ensure NAs provide care per policy. The facility’s urinary continence and incontinence policy directed that management of incontinence follow relevant clinical guidelines and that a check-and-change strategy be used at regular intervals to maintain dignity, comfort, and skin protection, which was not followed in this case.
Failure to Follow Mechanical Lift Protocols Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with diagnoses including unspecified dementia and anxiety, who was dependent on staff for all transfers and required a mechanical lift with the assistance of two staff members, was transferred by a single nurse aide using the mechanical lift. The resident's care plan and physician's orders specified the use of a Hoyer lift with two staff for all transfers, and facility policy also required at least two nursing assistants for safe use of the mechanical lift. Despite these directives, the nurse aide performed the transfer alone, which was later confirmed during the facility's investigation. Following this unsupervised transfer, the resident was found to have multiple new skin tears on the hands, arm, and back of the head, as well as bruising on the thigh and pubic region. Subsequent assessment revealed an acute fracture of the left intertrochanteric hip. The incident was identified through clinical record review, staff interviews, and facility documentation, confirming that the transfer was not conducted according to the resident's care plan and established safety protocols.
Failure to Implement Baseline Care Plan for ADLs and Diabetes Management
Penalty
Summary
A deficiency was identified when the facility failed to implement a baseline care plan for a resident who required assistance with activities of daily living (ADLs) and had type 2 diabetes mellitus with hyperglycemia. Upon admission, the resident was noted to have an amputation of the right lower leg, required extensive assistance with transfers, and was non-ambulatory. Multiple assessments by nursing, occupational therapy, and physical therapy documented the resident's need for moderate to extensive assistance with ADLs, use of a Hoyer lift for transfers, and rehabilitation services. The resident also had moderately impaired cognition, was always incontinent of bowel, occasionally incontinent of bladder, and required insulin and other medications for diabetes management. Despite these documented needs, the baseline care plan in place from admission did not address the resident's requirements for ADL assistance or diabetes management. Physician orders specified the need for assistance with ADLs and transfers using a Hoyer lift, as well as a detailed regimen for diabetes medications and insulin administration. However, the baseline care plan failed to reflect these needs. Interviews with facility staff confirmed that the expectation was for a baseline care plan to be developed and implemented upon admission to address ADL status and disease management, but this was not done for the resident in question.
Incomplete Documentation of Hypoglycemia Management
Penalty
Summary
The facility failed to ensure that the medical record for a resident with diabetes was complete and accurate in documenting the treatment of multiple hypoglycemic episodes. The resident, who had a history of type 2 diabetes, cognitive impairment, and other significant health conditions, experienced several instances where blood glucose levels were critically low. On multiple occasions, blood sugar readings were recorded as being below 60, and interventions such as administration of Glucagon and nutritional supplements were provided. However, the clinical record did not consistently reflect timely rechecks of blood glucose levels within 15 minutes as required, nor did it always document the interventions taken, the resident's response, or provider notifications. Nursing staff interviews revealed that although follow-up blood sugar checks were reportedly performed and the resident was monitored, these actions were not always entered into the resident's clinical record. The responsible LPN admitted to forgetting to document some of the follow-up blood sugar results, despite performing them. Additionally, the RN supervisor acknowledged that updates to the provider were sometimes only recorded in supervisor reports rather than in the resident's clinical record, leading to incomplete documentation of the care provided and the communication with the provider. The Director of Nursing confirmed that the facility's expectation and policy required nurses to document all blood sugar readings, interventions, resident responses, and follow-up actions in the clinical record, especially when blood glucose levels were below 70. The review of the facility's hypoglycemia management policy further supported the need for thorough documentation of interventions and follow-up blood glucose checks. The lack of complete and accurate documentation in the resident's medical record constituted a failure to maintain records in accordance with accepted professional standards.
Failure to Document Food Temperatures Before Meal Service
Penalty
Summary
The facility failed to ensure that dietary staff consistently monitored and documented food temperatures prior to meal service. Specifically, the Service Line Checklists from 12/1/24 through 1/12/25 did not record food temperatures on several dates, including 12/2/24, 12/23/24, 12/25/24, 12/31/24, 1/1/25, 1/2/25, and one undated checklist. During an observation and interview on 1/14/25, a dietary staff member confirmed that temperatures are typically taken once food is on the steam table, but the documentation was missing for the specified dates. The Dietary Manager acknowledged awareness of the incomplete checklists and admitted that she had not followed up with the responsible cook due to a busy schedule. She believed that the cook likely took the temperatures but failed to document them. The facility's policies require that food temperatures be monitored to ensure safety and quality, yet these procedures were not adhered to. The Administrator was unaware of the missing documentation and expected that temperatures would be recorded for every meal, as per the facility's policies on food preparation and service.
Resident Rights Violation Due to Disrespectful Interaction
Penalty
Summary
The facility failed to ensure that a resident was treated in a respectful and dignified manner, as required by resident rights. Resident #39, who had a history of hemiplegia/hemiparesis following a stroke and was at risk for falls, was involved in an incident where a nurse aide (NA #12) made a disrespectful comment. During an interview, Resident #39 reported that after requesting a food item, NA #12 responded with a comment about not understanding food deprivation because he was not from an African American background, which the resident found disrespectful. NA #12, during an interview, denied making the specific statement but acknowledged discussing the resident's meal choices. He recalled suggesting that Resident #39 eat the meal tray before consuming cookies. The Director of Nursing Services (DNS) confirmed that NA #12 had advised the resident to eat the meal first, which was deemed inappropriate as it disregarded the resident's right to food preferences. The facility's policy on Resident Rights mandates that all residents be treated with kindness, respect, and dignity, which was not upheld in this instance.
Failure to Conduct Interdisciplinary Care Conferences
Penalty
Summary
The facility failed to consistently hold interdisciplinary resident care conferences and invite the resident to participate, as required for person-centered care planning. Resident #45, who was admitted in November 2020 with various diagnoses including chronic embolism, thrombosis, and major depression, had intact cognition and was independent in certain activities of daily living. Despite this, the facility did not conduct the required quarterly interdisciplinary care conferences for over a year and a half, with the last one held on April 13, 2023. This resulted in six missed quarterly conferences, and the resident expressed a desire to attend these meetings, which had not been held for about two years. Interviews with facility staff revealed systemic issues in scheduling and conducting these care conferences. RN #7, the MDS coordinator, admitted to not attending the meetings due to time constraints and a lack of additional staff support, despite being aware of the expectation to attend. The responsibility for scheduling these conferences was placed on the social worker, who also faced challenges in ensuring the attendance of the interdisciplinary team. The social worker confirmed that only she attended the scheduled meetings with Resident #45, which did not meet the requirements for a comprehensive interdisciplinary care conference. The facility's policy mandates that a comprehensive, person-centered care plan be developed and implemented by an interdisciplinary team, including the resident and their representative. However, the lack of participation from key team members, such as the attending physician, registered nurse, and dietitian, among others, led to a failure in meeting these requirements. The social worker documented these meetings as interdisciplinary care conferences, although they were essentially one-on-one meetings, highlighting a significant deficiency in the facility's care planning process.
Failure to Inform Resident Representative of Admission Rights
Penalty
Summary
The facility failed to inform a resident's representative of their rights upon admission, as required by regulations. The resident, who was admitted with conditions including stroke, gastrostomy placement, and dysphagia, had severely impaired cognition and was nonverbal. Despite an admission care conference being held with the resident's representative, the facility did not review or request a review of any admission documents with the representative. The clinical record contained blank admission documents, including consents for treatment, personal item inventory, and various policies, indicating that the necessary paperwork was not completed. The Admissions Director attempted to contact the resident's representative on three occasions but did not succeed and did not make further attempts or notify the DNS or Administrator. The DNS confirmed that the admitting nurse was responsible for completing the admission paperwork within 48 hours and should have ensured its completion by reporting to the next oncoming nurse if necessary. The facility's admission agreement, which was unsigned and undated, outlined the legal obligations and rights of the resident and the facility, but these were not communicated to the resident's representative, leading to the deficiency.
Failure to Obtain Timely Physician Orders for Advance Directives
Penalty
Summary
The facility failed to obtain a physician's order for code status for three residents after their advance directives were communicated and documented. Resident #16, who was admitted with vascular dementia, Alzheimer's disease, and malignant neoplasm, had an Advance Directives-Clarification of Wishes document indicating a Do Not Resuscitate (DNR) status, among other wishes. However, a physician's order reflecting these wishes was not written until 11 months later. The Director of Nursing Services (DNS) expected that advance directives would be addressed within 48 hours of admission, but this was not met for Resident #16. Resident #41, admitted with Alzheimer's disease, epilepsy, and schizoaffective disorders, had a documented wish for Full Code status. Despite this, the care plan and physician's orders did not reflect the resident's advance directives. The DNS confirmed that a physician's order should have been obtained within 48 hours of admission, but it was not until after surveyor inquiry that a physician's order was documented. For Resident #44, who had a stroke and severely impaired cognition, the facility failed to review advance directives upon admission. Although a physician's order for DNR was present, the admission note did not document a discussion of advance directives. The DNS identified that the admitting nurse should have completed the advance directives paperwork within 48 hours, but this was not done. The DNS noted multiple residents lacked signed advance directives, indicating a systemic issue in the facility's process for handling advance directives.
Failure to Notify Resident Representative of Hospital Transfers
Penalty
Summary
The facility failed to notify the resident representative of a change in condition and hospital transfers for a resident with a history of stroke, gastrostomy placement, and dysphagia. The resident was dependent on tube feeding and had severely impaired cognition, requiring staff assistance for daily activities. On two occasions, the resident inadvertently pulled out the gastrostomy tube, leading to hospital transfers for reinsertion. Despite these significant changes in the resident's condition, the facility did not notify the resident's representative promptly as required by their policy. On the first occasion, the resident pulled out the gastrostomy tube, and after an unsuccessful attempt to reinsert it, the resident was sent to the hospital. The clinical record did not show that the resident's representative was informed of this transfer. The representative only learned of the situation from the hospital staff, which caused distress as they were unaware of the resident's departure from the facility. The second incident occurred when the resident again dislodged the gastrostomy tube, resulting in another hospital transfer. The facility failed to notify the resident's representative of this transfer as well. The representative was only informed when the resident was being readmitted to the facility. Interviews with the RN involved revealed that while he believed he had contacted the representative, there was no documentation to support this, and he admitted to not always calling immediately due to the timing of his shifts.
Failure to Update Care Plans After Feeding Tube Dislodgements
Penalty
Summary
The facility failed to update the comprehensive care plan for two residents following multiple displacements of feeding tubes. Resident #37, who had a gastrostomy-jejunostomy (GJ) tube, experienced two dislodgements of the tube. Despite these incidents, the care plan was not updated with new interventions. The Director of Nursing Services (DNS) acknowledged that the care plan should have been revised after each dislodgement, and the nursing staff had implemented different interventions, such as frequent checks and positioning techniques, but these were not documented in the clinical record. Resident #44, who had a gastrostomy tube, also experienced two dislodgements. The care plan did not reflect these incidents or include interventions to address them. Although the MDS Coordinator reviewed and revised the care plan, the revision did not address the tube dislodgements. The DNS identified that it was the responsibility of the nursing staff to complete care plan revisions related to such incidents, and the MDS Coordinator was responsible for revisions related to hospitalizations or transfers. The facility's policy on comprehensive care plans directs that the care plan must be reviewed and updated when there is a significant change in the resident's condition, when the resident is readmitted from a hospital stay, and at least quarterly. However, the care plans for both residents were not updated as required, leading to a deficiency in the facility's compliance with its own policy and regulatory requirements.
Failure to Provide Meal Setup Assistance
Penalty
Summary
The facility failed to provide necessary setup and assistance with meals for a resident with hemiplegia/hemiparesis following a stroke, as per the comprehensive assessment and plan of care. The resident, who was cognitively intact, required substantial assistance with bed mobility, two-person assist with transfers using a mechanical lift, and setup assistance with eating. Despite these needs, the resident reported that a nurse aide occasionally dropped off the food tray without opening or setting up food items, leaving the resident feeling intimidated and reluctant to request the needed assistance. The nurse aide involved stated that he provided setup assistance to all residents assigned to him but was not usually assigned to this particular resident. He admitted to providing setup assistance with meals only if he remembered and when requested. The Director of Nursing Services (DNS) confirmed that staff were expected to ask all residents if assistance was needed with meals, regardless of assignment. The facility's policy for Activities of Daily Living (ADL) Support mandates that residents be provided with care and services appropriate to maintain or improve their ability to carry out ADLs, including dining support and assistance.
Failure to Complete Neurological Assessments After Falls
Penalty
Summary
The facility failed to ensure that neurological assessments were completed for two residents after unwitnessed falls and a head strike. Resident #12, who had a history of falls and was admitted with vascular dementia and other conditions, experienced an unwitnessed fall on 5/28/24. Although an initial neurological check was documented, no further assessments were recorded as required by the facility's policy. The DNS, who was not in position at the time of the incident, confirmed that neurological checks should have been completed and documented on the flowsheet, but no such documentation was found. Resident #48, admitted with Parkinson's Disease and a history of falls, experienced multiple unwitnessed falls and a head strike incident. On several occasions, neurological assessments were either incomplete or not conducted at all. For instance, on 8/11/24, 13 out of 24 assessments were not completed following an unwitnessed fall. Similarly, on 11/29/24 and 12/2/24, neurological assessments were not completed as required. On 1/7/25, after a head strike incident, 10 out of 24 assessments were not completed, and the resident's refusal to undergo assessments was not properly managed or documented. Interviews with the DNS and nursing staff revealed a lack of adherence to the facility's neurological assessment policy. The DNS expected that all sections of the neurological assessments would be completed after unwitnessed falls or head injuries. However, staff failed to follow the protocol, and there was a lack of communication and documentation regarding the residents' refusals and the inability of staff to perform the assessments due to other duties. The facility's policy required that any changes in neurological status be reported to a physician, but this was not consistently done.
Failure to Conduct Weekly Skin Assessments Leads to Pressure Ulcer
Penalty
Summary
The facility failed to ensure that weekly skin assessments were completed for a resident with a high risk of developing pressure ulcers, as per the physician's order. The resident, who had severe cognitive impairment and was dependent on staff for mobility and hygiene, was admitted with multiple diagnoses including cerebral infarction and hemiplegia. The physician's order required weekly skin observations on shower days, specifically on Mondays during the 3:00 PM to 11:00 PM shift. However, documentation revealed that these assessments were not completed during several weeks, specifically on 10/14, 10/28, 11/4, 11/11, and 11/25. The resident was transferred to the hospital on 11/29 due to vomiting and a protrusion in the abdomen, and upon return to the facility on 12/4, was found to have a stage 3 pressure injury on the sacral region. Interviews with the LPN and DNS confirmed the lack of completed skin assessments during the specified weeks. The facility's policy required weekly full body audits to be documented in the resident's medical record, which was not adhered to, leading to the development of a pressure ulcer.
Inadequate Supervision and Assistive Devices Lead to Multiple Incidents
Penalty
Summary
The facility failed to provide adequate supervision and assistive devices to prevent accidents for several residents. Resident #23, who had a history of anoxic brain damage and psychotic disorder, eloped from the facility despite being assessed as low risk for elopement. The resident was found 0.4 miles away from the facility after the front door alarm sounded. The facility's elopement risk assessments were not completed as required, and there was a lack of supervision at the time of the incident. Resident #26, diagnosed with dementia and cerebrovascular disease, also eloped from the facility. Despite being identified as at risk for elopement, the care plan did not include interventions to address this risk. The resident left the facility without notifying staff and was found by the Admission Director 0.4 miles away. The facility concluded this was an unauthorized leave, but staff were unaware of the resident's departure. Resident #27, with severe morbid obesity and schizoaffective disorder, sustained injuries during a transfer using a hoyer lift. The resident's right leg was bruised and swollen, and it was determined that the injuries occurred when the resident's leg struck the lift during a transfer. The incident was not immediately reported by staff who noticed the injuries. Additionally, Resident #39 experienced a fall during a therapy session due to inadequate positioning in a wheelchair, and Resident #48 had an unwitnessed fall due to a broken wheelchair seat belt.
Failure to Prevent Feeding Tube Dislodgement Due to Inadequate Intervention and Education
Penalty
Summary
The facility failed to ensure proper interventions were in place to prevent the dislodgement of a feeding tube for Resident #37, who was admitted with a gastrostomy-jejunostomy (GJ) tube and other medical conditions such as cerebral infarction and hemiplegia. The care plan identified the risk of the GJ tube coming out and recommended the use of an abdominal binder as an intervention. However, observations revealed that the abdominal binder was not consistently used, and alternative measures like covering the tube with a towel were employed instead. The report highlights that the facility did not adequately educate the resident's family on the importance of the abdominal binder to prevent tube dislodgement. Interviews with nursing staff indicated that the resident's spouse, who does not speak English, often removed the binder, and there was a lack of effective communication and education provided to the spouse due to a language barrier. The facility had a language line available for such situations, but it was not utilized to ensure the spouse understood the necessity of the intervention. The deficiency was further compounded by the fact that the nursing staff did not document or communicate the importance of the abdominal binder to the resident's responsible party or spouse. Despite the facility's policy on enteral feeding safety precautions and comprehensive person-centered care planning, the interdisciplinary team failed to implement and communicate targeted interventions effectively, leading to repeated dislodgement of the resident's GJ tube and subsequent hospital visits for replacement.
Failure to Serve Meals at Appetizing Temperatures
Penalty
Summary
The facility failed to ensure meals were served at appetizing temperatures, as observed and reported by residents and staff. Interviews with four residents revealed frequent complaints about cold food. The Food Service Director (FSD) acknowledged occasional complaints and ongoing efforts to deliver hot food timely. The Administrator noted that food was not reaching residents promptly after delivery to the floor. A food temperature check conducted with the FSD showed that several hot food items, including a hamburger, hot dog, and grilled cheese, were served below the expected temperature of 140°F, with some items as low as 106.7°F. The Director of Nursing Services (DNS) was aware of periodic complaints and expected food to be served at adequate temperatures. The facility's policy directed that proper hot and cold temperatures be maintained during food service, with a 'danger zone' for holding temperatures between 41°F and 135°F, which promotes the growth of pathogenic organisms causing foodborne illness.
Infection Control Deficiencies in Hand Hygiene and Medication Administration
Penalty
Summary
The facility failed to adhere to infection control policies in several instances, leading to deficiencies in care. For Resident #50, who was at risk for pressure ulcers, an LPN did not perform hand hygiene after removing gloves and before touching items on the resident's bedside table. This was observed by the Infection Preventionist, and both the LPN and the Infection Preventionist acknowledged the lapse in protocol. The facility's policy clearly states that hand hygiene should be performed after removing gloves and between tasks, which was not followed in this instance. Additionally, during medication administration for Resident #5, an LPN failed to maintain infection control standards by touching medication with her hands instead of dispensing it directly into a medication cup as per facility policy. This oversight was acknowledged by the LPN and the Director of Nursing, who confirmed the expectation for safe infection control practices. Furthermore, the facility did not conduct monthly environmental infection control rounds consistently, as required, with several months missing documentation. The Infection Preventionist, responsible for these rounds, could not provide records for multiple months, indicating a lapse in the facility's infection control oversight.
Failure to Administer and Document Vaccinations
Penalty
Summary
The facility failed to offer influenza and pneumococcal vaccinations to two residents, provide education regarding the benefits and potential side effects of these immunizations, or document in the clinical records whether the residents received or declined the vaccinations. Resident #44, who was admitted with diagnoses including pneumonia and stroke, did not have documentation in the clinical record from 9/30/24 to 1/14/25 indicating that the influenza vaccine was offered or administered. The Preventative Health Report also failed to show that Resident #44 received the influenza or pneumococcal vaccines. The Infection Preventionist (RN #3) acknowledged the lack of documentation and confirmed that the resident's representative was not contacted regarding the influenza vaccine. Similarly, Resident #61, admitted with chronic obstructive pulmonary disease and other conditions, was not offered the influenza or pneumococcal vaccines, and there was no documentation of education or vaccination status in the clinical record from 9/30/24 to 1/14/25. The Preventative Health Report did not reflect that Resident #61 received the vaccines. RN #3 confirmed that the vaccination forms were blank and not addressed upon admission. The facility's policies require that residents be offered these vaccines and educated about them, with documentation of education and vaccination status in the medical record, which was not adhered to in these cases.
Failure to Offer and Track COVID-19 Vaccinations for Residents
Penalty
Summary
The facility failed to ensure that two residents, Resident #44 and Resident #61, were offered COVID-19 immunizations and that their vaccination statuses were properly tracked. Resident #44, who was admitted with diagnoses including pneumonia, stroke, and a feeding tube, had severely impaired cognition. The Preventative Health Report indicated that Resident #44's COVID-19 vaccine was last administered on January 15, 2023, and was not up to date. The Infection Preventionist, RN #3, acknowledged that although the resident could receive a booster dose, he did not reach out to the resident's representative to educate and offer the vaccine. Resident #61, admitted with chronic obstructive pulmonary disease, acute respiratory failure, and insulin-dependent diabetes, had moderately impaired cognition. The Preventative Health Report did not document Resident #61's COVID-19 immunization status, and the COVID-19 vaccine form was left blank in the chart. RN #3 admitted that he was responsible for following up on the vaccination status but failed to do so. The Director of Nursing Services and the Regional Clinical Nurse confirmed that RN #3 was responsible for ensuring that all residents were offered the COVID-19 vaccine or boosters upon admission and when doses were due, but this was not done for Resident #61.
Late Submission of PBJ Report
Penalty
Summary
The facility failed to submit the 4th quarter Payroll Based Journal (PBJ) report on time. The report, covering the period from July 1, 2024, to September 30, 2024, was due by October 14, 2024, at 11:59 PM but was instead submitted on October 15, 2024, at 10:47 AM. This delay occurred because the Director of Human Resources, following instructions from a corporate staff member, held the report to wait for all PBJ reports from all sites to be reviewed before submission. Consequently, the PBJ submission was not timely, and the facility could not provide a policy for PBJ submission when requested.
Failure to Secure Resident's Money
Penalty
Summary
The facility failed to ensure the security of a resident's money that was placed in their possession. Resident #1, who had diagnoses including cerebrovascular disease and dementia, entrusted $2,000 in cash to the facility's business office. The money was stored in a safe that was unable to be locked due to staff not knowing how to operate the dial lock. The safe had been left unlocked and unsecured for at least two years. On 10/23/23, when Resident #1 requested their money, it was discovered that the envelope containing the $2,000 was empty. The facility was unable to determine who misappropriated the money. The business office door was always locked, but the key was accessible to multiple staff members, including those in maintenance, which compromised the security of the safe's contents. The Administrator admitted that despite previous attempts to contact locksmiths, no documentation was provided to support these efforts. The facility's policy directed that reasonable efforts should be made to safeguard residents' personal property, but this was not adhered to in this case. The Business Manager confirmed that the safe's door was closed but not locked, and the money was last observed on 10/12/23. The facility's failure to secure the safe and properly safeguard the resident's money led to the misappropriation incident.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 835 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cheshire
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elim Park Baptist Home, Inc | 3.5 mi | ★★★★★ | 0 | 0 |
| Livewell Connecticut | 3.8 mi | ★★★★★ | 1 | 0 |
| Cheshire House Health Care Facility & Rehab Center | 4.5 mi | ★★★★★ | 2 | 0 |
| Silver Springs Care Center | 4.8 mi | ★★★★★ | 4 | 0 |
| Curtis Home St Elizabeth Center, The | 4.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.