Cheshire House Health Care Facility & Rehab Center

In the surveyor’s words

From the most serious findings on record at Cheshire House Health Care Facility & Rehab Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812May 27, 2021

  Based on observation, facility documentation, facility policy, and interviews, the facility failed to discard expired food items and ensure food items were dated or labeled. The findings include: 1. Tour of the Dietary Department and interview with the Dietary Supervisor on [DATE] at 10:15 AM identified the following: a. The main Dietary walk in refrigerator was noted to contain 2 cooked apple pies on the shelves dated [DATE] (6 days old) and a metal bowl with chopped carrots, celery and onions dated [DATE] (4 days old). b. […]

• No harm, potential for more than minimal, patternF689Apr 22, 2025

  Based on clinical record reviews, observations, facility documentation, facility policy and interviews for 3 of 8 sampled residents (Resident #10, Resident #58 and Resident #219) reviewed for dining, the facility to provide adequate supervision during mealtime for residents with a history of aspiration. The findings include: 1. Resident #10 had diagnoses that included dysphagia (swallowing disorder), blindness and Alzheimer's dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #10 had moderately impaired cognition, was highly visually impaired, and independent with eating. […]

• No harm, potential for more than minimal, patternF695Apr 22, 2025

  Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 5 of 6 residents (Resident #1, Resident #2, Resident #15, Resident #219 and Resident #269) reviewed for respiratory therapy, the facility failed to date oxygen tubing per facility policy (Resident #2, Resident #15, Resident #219 and Resident #269) and failed to appropriately store nebulizer tubing for a resident with pneumonia (Resident #2) and chronic respiratory failure (Resident #269) and failed to complete every shift oxygen saturations (Resident #1). The findings include: 1. […]

• No harm, potential for more than minimal, patternF756Apr 22, 2025

  Based on review of the clinical record, interviews, and review of facility policy, for 2 of 5 residents, (Resident #12 and Resident #269) reviewed for unnecessary medications, the pharmacist failed to identify behavior monitoring was not completed for residents receiving antipsychotic medication. The findings include: 1. Resident #12's was re-admitted to the facility in August 2024 with diagnoses that included vascular dementia, major depressive disorder and anxiety. A Resident Care Plan (RCP) dated 8/28/24 identified Resident #12 was at risk for potential adverse effects of psychotropic drug use related to being prescribed psychotropics for depression and/or anxiety. […]

• No harm, potential for more than minimal, patternF758Apr 22, 2025

  Based on review of the clinical record, interviews, and review of facility policy, for 2 of 5 residents (Resident #12 and Resident #269) reviewed for unnecessary medications, the facility failed to identify and monitor target behaviors for residents receiving antipsychotic medications. The findings include: 1. Resident #12 was re-admitted to the facility in August 2024 with diagnoses that included vascular dementia, major depressive disorder and anxiety. A Resident Care Plan (RCP) dated 8/28/24 identified Resident #12 was at risk for potential adverse effects of psychotropic drug use related to being prescribed psychotropics for depression and/or anxiety. […]