Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Cheshire Home during CMS and state inspections, most recent first.
Soiled room surfaces detracted from a resident’s homelike environment. A surveyor observed reddish-brown crusted substance on the ceiling gridwork and bathroom door frames, along with black stains on the HVAC diffuser in the resident’s room. The resident, who had paraplegia and a tracheostomy and had intact cognition per MDS, stated the ceiling and ventilation cover did not look nice and were in need of cleaning or replacement. The MD confirmed the conditions should have been repaired and had no open work orders or reports for them.
The facility failed to follow its abuse policy by not completing criminal background checks before hire for 2 of 47 new staff members. A driver and an LPN both had background screening reports dated after their dates of hire, and one file also lacked references. The HRD stated background checks were completed prior to hire, but the reviewed files showed otherwise.
A resident with paraplegia and intact cognition was prescribed Sertraline HCl 25 mg daily for depression, but the comprehensive care plan did not include a care plan for the antidepressant medication. An LPN stated antidepressants should be included in the care plan, and the DON said the facility usually does a care plan for antidepressants.
A facility failed to complete and document physician-ordered weekly skin assessments for two high-risk residents. One resident had quadriplegia, a stage III pressure ulcer, and chronic osteomyelitis, and the EMR lacked several scheduled weekly skin checks. Another resident with quadriplegia and TBI had a weekly skin check order, but after a certain point the EMR had no documented weekly skin assessments even though the TAR was signed. Staff interviews confirmed the documentation gap, and the facility policy required weekly skin check documentation in the medical record.
A resident with cognitive intactness but physical limitations was observed twice with their call light out of reach, contrary to their care plan and facility policy. The LPN confirmed the oversight, and facility management acknowledged the deficiency.
The facility failed to complete reference checks for two newly hired staff members, an LPN and an RN. The surveyor found no documented reference checks in their files, despite the facility's policy to seek maximum references. The Acting HR Representative, who took over after the previous HR left, could not provide information on these hires. An inquiry form for the RN was incomplete, and no response was received. The facility's policy, last revised in 1996, was not followed, and the issue was acknowledged by the LNHA and AA.
The facility failed to provide adequate care and documentation for two residents with pressure ulcers. One resident lacked proper documentation and assessment of wounds, and the care plan did not reflect current wound status. Another resident had a Stage 4 pressure ulcer without a formal risk assessment or consistent documentation. Interviews revealed a lack of formal risk assessment processes and inconsistent wound documentation.
A resident using an external urinary catheter managed their own drainage bag, which was observed with uncovered tubing, contrary to infection control practices. Interviews with staff revealed inconsistencies in the understanding of proper storage procedures, and facility documentation lacked specific guidance on the care of external catheters. The care plan did not address the resident's catheter use, and there was no documented education provided to the resident.
A facility failed to change a resident's nebulizer and suction setups as per physician orders, despite having a checklist for respiratory equipment maintenance. The resident, who had a tracheostomy and other health conditions, was observed with outdated equipment. Staff acknowledged the oversight, and the survey team discussed the findings with facility management.
The facility failed to post the Nursing Home Resident Care Staffing Report (NHRCSR) at the beginning of the current shift on two occasions. The Unit Clerk and a nurse were responsible for posting the NHRCSR, but it was not updated for the current day, violating the facility's policy. Interviews confirmed the lapse, with the charge nurse ultimately responsible for ensuring compliance.
A resident with chronic pain was prescribed PRN Oxycodone and Acetaminophen to be administered together for severe pain. However, records showed discrepancies in administration, with Acetaminophen not given as frequently as Oxycodone. Nursing staff confirmed the oversight, and the Consultant Pharmacist failed to identify this irregularity in their monthly review, leading to a deficiency.
A facility failed to provide timely lab services for a resident, neglecting psychiatric recommendations for liver enzyme monitoring and routine lab orders for CBC and CMP. The resident, who was cognitively intact and on medications requiring lab monitoring, did not receive the necessary tests. The DON acknowledged inconsistencies in lab requisition processes, but no explanation or additional information was provided to address the deficiency.
The facility failed to follow proper infection control practices, as a Physical Therapist did not change gloves or disinfect equipment between residents, and laundry areas had issues with dust accumulation and improper storage of soiled clothing. The facility's management was informed, revealing gaps in staff training and monitoring of infection control protocols.
Soiled Room Surfaces Detracted From Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment in 1 of 12 resident rooms observed. In Resident #7’s room, the surveyor observed a reddish-brown crusted substance on the ceiling gridwork slats and black stains on the HVAC diffuser in the center of the room. The surveyor also observed reddish-brown crusted substance on the bathroom door frames. Resident #7, who was admitted with diagnoses including paraplegia and a tracheostomy, had a Quarterly MDS dated 10/8/25 showing a BIMS score of 15 out of 15, indicating no cognitive deficits. The resident stated being upset that the ceiling gridwork and ventilation cover were soiled and in need of cleaning and maybe replacement. The Maintenance Director stated the facility used a paper reporting system for maintenance issues and that staff place reports in a box outside the maintenance office. He also stated he regularly rounds the building and rooms to assess for issues, but he did not have a formal log or documentation of those rounds. When the surveyor asked about the stained HVAC diffuser and the reddish-brown substance on the ceiling gridwork and bathroom door jambs, the Maintenance Director agreed these conditions detracted from the resident’s homelike environment and should be repaired, and confirmed there were no open maintenance work orders or reports for those conditions. The LNHA later confirmed that these conditions detracted from the facility’s home-like environment and should not occur.
Late Background Checks for New Hires
Penalty
Summary
The facility failed to follow its abuse policy to ensure criminal background checks were completed prior to hire for 2 of 47 newly hired staff members. Review of Staff #45’s file, a driver with a date of hire of 11/25/24, showed a background screening report dated 12/9/24, and no references were found in the file, indicating the screening was completed after the hire date. Review of Staff #47’s file, an LPN with a date of hire of 3/25/25, showed a background screening report dated 3/26/25, also completed after the hire date. During interview, the HRD stated that background screening reports were completed prior to a new employee’s date of hire, but the surveyor identified these two files as exceptions. The facility’s Abuse Prohibition Policy and Procedures, last revised October 2017, stated under the pre-hire screening procedure that each new hire will undergo a criminal background check and business reference checks.
Missing Care Plan for Antidepressant Medication
Penalty
Summary
A comprehensive, person-centered care plan was not developed for a resident who was receiving antidepressant medication. Resident #5 was admitted with paraplegia and had intact cognition on the admission MDS, with a BIMS score of 15 out of 15. The resident’s order summary showed Sertraline HCl 25 mg by mouth daily for depression, with an order date of 12/17/25. On review of the resident’s comprehensive care plan, no care plan was found for the use of antidepressant medication. During interview, the LPN stated that antidepressant medications should be included in the care plan. The DON stated that the facility usually does a care plan for antidepressants. The facility policy titled Medical Records Resident Care Planning stated that a compliant LTC care plan typically includes interventions, including the specific services, treatments, and items provided by the facility to reach goals.
Missed Weekly Skin Assessments for Two High-Risk Residents
Penalty
Summary
The facility failed to ensure that physician-ordered weekly skin assessments were completed at the required intervals for 2 residents who were at high risk for skin breakdown. Resident #3 was admitted with quadriplegia, a stage III pressure ulcer of the right buttock, and chronic osteomyelitis. The quarterly MDS reflected limited range of motion, inability to turn and reposition, and high risk for skin breakdown. A physician order dated 4/4/24 directed staff to complete a weekly skin check tool every Friday night shift, but the EMR did not document weekly skin assessments for 11/29/25, 12/12/25, 12/19/25, or 12/26/25. The WN reviewed the record and confirmed the missing weekly skin assessments. Resident #33 was admitted with diagnoses including quadriplegia and traumatic brain injury, and the quarterly MDS coded the resident as at risk for pressure ulcers/injuries. A physician order dated 12/15/25 directed staff to complete a weekly skin check tool every Thursday night shift for skin integrity. The resident also had care plan interventions calling for weekly skin inspection and weekly skin checks per facility protocol. Although the December 2025 and January 2026 TAR showed the weekly skin check entry was signed as administered, the EMR assessment section contained no documented weekly skin assessments after 12/18/25, and there were no progress notes documenting completion of the weekly skin checks. During interviews, the LPN stated that signing the TAR indicated the weekly skin check assessment had been documented in the EMR and that the resident's skin had been assessed. The DON stated the weekly skin check signed in the TAR should correspond to a documented assessment in the EMR and that this was the only documentation indicating completion of the weekly skin check. The DON later stated the resident's shower day had changed and that there may have been a lack of communication between staff and the resident. The facility policy stated that weekly skin check documentation should be in the medical record and performed every week on the scheduled shower day, and the wound management policy required comprehensive weekly pressure ulcer documentation.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was readily accessible within reach, which was identified during a survey. The surveyor observed the resident, who was alert and verbally responsive but had slurred speech, sitting in a wheelchair beside the bed with the call light placed on the opposite side of the bed against the wall, out of reach. This observation was made on two separate occasions. The resident's medical record indicated diagnoses of diffuse Traumatic Brain Injury and neuromuscular dysfunction of the bladder, with cognitive intactness but limitations in both upper and lower extremities. The care plan for the resident included an intervention to ensure the call light was within reach, highlighting the facility's failure to adhere to this plan. During an interview, the LPN assigned to the resident confirmed that the call light should be within the resident's reach and acknowledged the oversight when the surveyor pointed it out. The facility's policy on making an open bed also stipulated that the call bell should be within the resident's reach, which was not followed in this instance. The facility management, including the DON and LNHA, acknowledged the findings and the requirement for call lights to be accessible to all residents.
Failure to Complete Reference Checks for New Hires
Penalty
Summary
The facility failed to ensure that reference checks were completed for two out of six newly hired staff members, specifically a Licensed Practical Nurse (LPN) and a Registered Nurse (RN). The surveyor's review of the employee files revealed that there were no reference checks documented for these two staff members. The Licensed Nursing Home Administrator (LNHA) and the Administrative Assistant (AA) were informed of this issue, and the AA indicated that she would follow up with the Acting Human Resources Representative (AHRR). The AHRR, who began covering the HR position after the previous representative left in May 2024, stated that the facility typically requested two references from new employees and used a facility inquiry form to contact previous employers. However, the AHRR could not provide information on the reference checks for the two staff members in question as they were hired before she assumed her role. The surveyor was provided with a copy of an inquiry form that was faxed to a previous employer of the RN, but it was not completed, and no response was received. The facility's policy on Personnel Management Reference Checks, last revised in 1996, stated that the facility would seek the maximum number of references possible to obtain a solid work ethic and character background. Despite this policy, the facility did not have documented reference checks for the two staff members, which was acknowledged by the AA and the LNHA. No additional information was provided by the facility to address this deficiency.
Deficient Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for two residents with pressure ulcers. Resident #8, who was cognitively intact and had diagnoses including quadriplegia, was observed with pressure ulcers but lacked proper documentation and assessment of these wounds. The care plan for Resident #8 did not reflect the current status of the resident's wounds, and there was no consistent weekly documentation of wound assessments, including measurements and descriptions. The Director of Nursing (DON) acknowledged the lack of formal investigation reports for new wounds and stated that there was no formal assessment tool used to assess residents' risks for wounds. Resident #9, who also had quadriplegia and a history of pressure ulcers, was found to have a Stage 4 pressure ulcer that was not present upon admission. The facility did not use a formal assessment tool like the Braden Scale to determine the resident's risk for pressure ulcer development, and there was no documented evidence of a clinical assessment related to the risk of developing pressure ulcers. The care plan for Resident #9 included interventions for monitoring wound healing, but there was no consistent weekly documentation of the pressure ulcer assessments, including measurements and descriptions. Interviews with facility staff, including the DON, Assistant DON, and nursing staff, revealed that the facility did not have a formal risk assessment process for pressure ulcers, and documentation of wound assessments was inconsistent. The facility's policies on wound management and prevention did not include information about risk assessment for pressure ulcer development. The surveyor noted that the facility did not provide additional information or documentation to address the concerns raised during the survey.
Inadequate Storage and Care of Urinary Drainage Bags
Penalty
Summary
The facility failed to provide appropriate care and services for the storage of urinary drainage bags for a resident using an external urinary catheter. The deficiency was identified during observations and interviews conducted by the surveyor. The resident, who was cognitively intact and had a history of paraplegia and neuromuscular dysfunction of the bladder, used an external urinary catheter at night and managed the drainage bag independently. However, the drainage bag was observed hanging at the bedside with uncovered tubing, which was not in line with infection control practices. Interviews with the Certified Nurse Aide (CNA) and Licensed Practical Nurses (LPNs) revealed inconsistencies in the understanding and implementation of proper storage procedures for urinary drainage bags. The CNA acknowledged that the resident preferred to manage their own drainage bag, but noted that the bag should be capped and stored in a plastic bag, which was not done. The LPNs provided conflicting information about the storage and disposal of drainage bags, with one LPN indicating that the bags should be capped and stored, while another suggested they were disposable and should be replaced. The facility's documentation and policies did not adequately address the care and storage of external urinary catheters and drainage bags. The care plan for the resident did not include specific interventions for managing the external catheter and drainage bag, and there was no documentation of education provided to the resident regarding proper care. Additionally, the facility's policy on urinary tract infections did not cover external catheters or the storage of urinary drainage bags, contributing to the deficiency in care provided to the resident.
Failure to Change Respiratory Equipment as Ordered
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident, specifically in changing nebulizer setups and suction tubing as per physician orders. During an initial tour, a surveyor observed a resident with a tracheostomy who reported receiving daily nebulizer treatments. The nebulizer tubing was labeled with a date, indicating it had not been changed as required. The resident's medical history included tracheostomy, paraplegia, hemiplegia, and major depressive disorder, and they were cognitively intact according to a recent assessment. The physician's orders specified that the nebulizer setup should be changed every day shift starting on the 24th of each month, and the suction canister, tubing, and filter should also be changed on the same schedule. However, the electronic Medication Administration Record (eMAR) indicated that these changes were not documented as completed. Interviews with staff, including a Licensed Practical Nurse (LPN) and an Infection Preventionist/Registered Nurse (IP/RN), revealed that the nebulizer and suction setups were not changed as scheduled, which was acknowledged as unacceptable practice. The facility's Respiratory Equipment Set-up checklist required the nebulizer setup to be changed weekly and the suction machine setup monthly, with labeling and dating. Despite these guidelines, the surveyor found that the equipment was not changed according to the schedule, and the staff acknowledged the oversight. The survey team discussed these findings with the facility management, who did not provide additional information during the exit conference.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the daily posting of the Nursing Home Resident Care Staffing Report (NHRCSR) at the beginning of the current shift for two out of four days during the survey. On two separate occasions, the surveyor observed that the NHRCSR was not updated for the current day, with reports from the previous day still posted. Specifically, on the morning of 9/03/24 and 9/05/24, the NHRCSR for the current day was missing, indicating a lapse in the facility's compliance with staffing information posting requirements. Interviews with facility staff revealed that the Unit Clerk (UC) was responsible for posting the NHRCSR for the day and evening shifts, while a nurse was tasked with posting it for the night shift. The UC acknowledged that the NHRCSR might be posted late and indicated that the charge nurse was ultimately responsible for ensuring the report was posted for each shift. The facility's policy, titled 'Staffing Nursing Staffing Information,' mandates that the nurse staffing data be posted daily at the beginning of each shift, which was not adhered to on the observed days.
Failure to Administer PRN Medications as Ordered
Penalty
Summary
The facility failed to identify and address an irregularity in the administration of as-needed pain medications for a resident, leading to a deficiency. The resident, who was cognitively intact and had a history of quadriplegia, chronic pain, and other conditions, was prescribed PRN Oxycodone and PRN Acetaminophen to be administered together for severe pain. However, the facility's records showed discrepancies in the administration of these medications, with PRN Acetaminophen not being given as frequently as PRN Oxycodone, contrary to the physician's order. The surveyor's review of the electronic Medication Administration Record (eMAR) for July, August, and September 2024 revealed that PRN Acetaminophen was not administered as ordered alongside PRN Oxycodone on numerous occasions. Interviews with nursing staff confirmed that the medications were not consistently signed off together, and the Licensed Practical Nurse acknowledged the oversight in documentation. Despite the facility's policy requiring a licensed pharmacist to conduct a monthly drug regimen review and report any irregularities, the Consultant Pharmacist did not identify or document this issue in their reports. The deficiency was further highlighted during interviews with the Registered Nurse Supervisors and the Consultant Pharmacist, who admitted to not addressing the irregularity in the monthly Medication Regimen Review. The facility's management was informed of these findings, but no additional information was provided to address the concerns raised by the survey team. The facility's policy mandates that any irregularities be reported in writing to the attending physician, medical director, and Director of Nursing, which was not adhered to in this case.
Failure to Ensure Timely Laboratory Services
Penalty
Summary
The facility failed to ensure timely and appropriate laboratory services for a resident, specifically regarding psychiatric recommendations and routine lab orders. The deficiency was identified for a resident who was cognitively intact and had multiple diagnoses, including quadriplegia, chronic pain, major depressive disorder, and hypertension. The resident was receiving medications such as Baclofen, Cymbalta, and Trazodone, which required regular monitoring through lab tests. The surveyor found that the facility did not follow the psychiatric recommendation from July 2024 to monitor liver enzymes ALT and AST every 3-6 months. Additionally, routine lab orders for CBC and CMP, scheduled for January and June 2024, were not conducted as required. The facility's Director of Nursing (DON) acknowledged that standing orders for labs should be electronically entered and executed according to physician orders, but inconsistencies in the process were noted, with some requisitions being handled manually. During interviews, the DON could not provide evidence that the lab orders were followed or explain why they were not. Despite being notified of the findings, the facility management did not offer additional information or documentation to address the concerns raised by the surveyor. The deficiency was reported to the Licensed Nursing Home Administrator, DON, and Administrative Assistant during an exit conference.
Infection Control Deficiencies in Hand Hygiene and Laundry Practices
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, as evidenced by the actions of a Physical Therapist (PT) and issues observed in the laundry areas. The PT was observed wearing the same pair of gloves while checking multiple residents' electric wheelchair cushions without changing gloves, performing hand hygiene, or disinfecting the handheld equipment used. This practice was contrary to the facility's policy and CDC guidelines, which require hand hygiene and equipment disinfection between patient interactions. The PT stated that he was instructed by his director to wear the same gloves, indicating a possible gap in staff training or communication. Additionally, during a tour of the laundry areas, deficiencies were noted in the handling and storage of linens and residents' clothing. In one laundry area, an electric fan with visible dust accumulation was blowing air onto uncovered clean linens, which were exposed to potential contamination. In another area, soiled residents' clothing was left uncovered and unattended on top of a washer, contrary to the facility's policy that requires soiled laundry to be bagged and properly stored. The District Manager from the contracted laundry service acknowledged these issues but did not provide a satisfactory explanation for the lapses in protocol. The facility's management, including the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA), were informed of these findings. It was revealed that residents using the laundry facilities were not educated on infection control practices, and there was no staff assigned to monitor the laundry area. The facility's policies on hand hygiene and soiled laundry collection were not being followed, contributing to the potential spread of infection within the facility.
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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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Nursing homes near Florham Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pine Acres Rehabilitation And Healthcare | 1.3 mi | ★★★★★ | 9 | 0 |
| Florham Park Rehabilitation And Healthcare Center | 1.5 mi | ★★★★★ | 7 | 0 |
| Careone At Livingston | 2.7 mi | ★★★★★ | 10 | 0 |
| Livia Health And Senior Living | 2.7 mi | ★★★★★ | 9 | 0 |
| Chatham Hills Subacute Care Center | 2.8 mi | ★★★★★ | 17 | 0 |
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