Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Complete Care At Meriden during CMS and state inspections, most recent first.
Medication administration errors caused the facility’s error rate to exceed the allowed threshold. An LPN gave several ordered meds to a resident with multiple chronic conditions, but two psychotropic meds were initially not available in the cart and were incorrectly signed off as given on the MAR. The LPN later acknowledged the error and administered the missed meds only after the discrepancy was identified. The MAR also did not reflect the PRN opioid given from the e-box as required.
The facility failed to maintain accurate clinical records when an LPN did not sign the MAR after administering scheduled meds, insulin, and supplements for a resident with chronic pain, diabetes, and clotting-related diagnoses on multiple shifts. The facility also failed to document wound care on the TAR for another resident with a stage 4 pressure ulcer, as an LPN, another LPN, and the ADNS stated they provided ordered heel and ischial treatments but did not sign the record. Facility policy required documentation at the time meds and wound treatments were given.
Urinary Drainage Bag Left Visible Without Privacy Cover: A resident with an indwelling foley catheter, neurogenic bladder, and diabetes was observed multiple times lying in bed with the urinary drainage bag attached to the bed frame and visible from the hallway without a privacy cover. The ADNS and DON stated urinary drainage bags must always be covered to protect dignity and privacy, and the facility policy required privacy bags to be available and catheter drainage bags to be covered while in use.
Failure to assess self-administration of medication: A resident with HTN, hepatitis C, kidney disease, and pruritus had Hydrocortisone 1% cream kept at the bedside without a pharmacy label or opened date. The resident said nursing staff provided the cream and left it at the bedside, while the DNS confirmed there was no documented assessment for safe self-administration in the clinical record.
Incomplete Advance Directives Documentation: A resident with DM2, CHF, and osteomyelitis had intact cognition, but the chart contained an unsigned and incomplete advance directives form and no signed advance directives were found in the paper chart or EMR. The resident was listed as Full Code in the care plan and on a physician order, while an RN manager and the DNS stated nurses were responsible for completing advance directives on admission and could not explain why the form had not been completed.
Unclean resident room and soiled wheelchair: A resident with chronic respiratory failure, tracheostomy, COPD, stroke, and a g-tube was observed in a room with a dirt-covered wheelchair, rusty soiled overbed tables, hardened drippings on the walls and radiators, and dirt buildup on the floor and corners. The Administrator acknowledged the buildup and said the room needed deep cleaning, while the DOR of Housekeeping could not verify completion of monthly deep cleaning or wheelchair cleaning rosters.
Failure to file a resident grievance about staff treatment. A resident with intact cognition and dependence for toileting and transfers voiced concerns that an aide was rude, humiliating, and did not treat him/her well, and said several nurses were told about the behavior. An LPN acknowledged hearing the complaint but did not report it, the DNS was unaware of the issue until survey inquiry, and grievance records contained no complaint for the resident despite facility policy requiring verbal grievances to be documented and forwarded promptly.
Failure to Update PASRR After New Psychiatric Diagnoses: A resident with dementia and new psychiatric diagnoses, including paranoid personality disorder and anxiety, had PASRR screening that did not fully capture the resident’s mental health status. The record showed the resident received antipsychotic and antidepressant meds and had psych evals for insomnia, anxiety, depression, agitation, dementia, and paranoia, but the PASRR contracted agency was not notified for an updated Level II review when the new diagnoses were identified.
A resident with HTN, hepatitis C, kidney disease, and pruritus had a tube of Hydrocortisone 1% cream left on the bedside table without a pharmacy label or opened date. The cream was identified as facility house stock, and the clinical record initially lacked a physician order for the medication; the DNS stated an order is required before any medication, including house stock, is administered.
Infection control and EBP PPE failures occurred during wound care and hands-on care. An LPN performing wound care for a resident with a stage 4 pressure ulcer placed supplies on an unclean bedside table and repeatedly changed gloves without hand hygiene, while also handling wound dressings incorrectly. In separate events, a NA and an ADNS provided care to two residents on EBP without wearing the required gown and gloves during high-contact activities such as rolling, incontinent care, and wound care.
A resident with mental health diagnoses and requiring ADL assistance was involved in a verbal altercation with a nurse aide, during which the aide spoke loudly, used inappropriate language, and repeated the resident's foul language back to them. Witnesses, including a dietary aide and an LPN, confirmed the aide's unprofessional conduct, which did not align with facility policies on resident rights and dignity.
A resident with cognitive impairment and a known risk for elopement exited the facility unsupervised after staff failed to properly investigate an emergency exit door alarm. Despite care plans and interventions such as a wander guard and scheduled visual checks, staff did not follow elopement protocols, resulting in delayed search and notification. The resident was later found by police at a nearby location after experiencing chest pain.
A resident with cognitive impairment and a history of wandering did not have a physician's order or care plan in place for a wanderguard, despite staff notes indicating its use and ongoing wandering behavior. Facility staff were unclear about when the device was applied, and required documentation and assessments were missing prior to the resident's elopement from the facility. The necessary care planning and monitoring interventions were only implemented after the resident was found outside the facility.
The facility experienced issues with food storage practices in the dry storage area, including an open bag of chocolate chips and detergent bottles stored alongside food items. Inconsistent documentation of daily meal temperatures was also observed, with missing entries in the logs. Improper food handling was noted, such as a cook using bare hands to handle hamburger rolls during plating. Additionally, maintenance issues with ice machines were identified, including pink debris buildup on the ice outlet and water overflow onto the floor. The buildup was attributed to improper use of ice containers with juice residue. Cleaning practices were found to be insufficient, with wet floors in the nourishment room and the need for manual emptying of ice machine catch trays. Housekeeping staff were unsure of the frequency for tray emptying.
The facility failed to obtain consent and physician's orders for bed rails for six residents, did not perform annual bed rail inspections, and did not follow its policy for bed rail use and maintenance.
The facility failed to ensure that a resident with dementia had their diagnosis reflected in their care plan and did not include a facial hematoma in another resident's care plan despite a physician's order to monitor it. Interviews confirmed that it was the responsibility of the MDS Coordinator and nurses to update care plans as needed.
The facility failed to revise the care plan for a resident with dementia and Alzheimer's disease regarding the utilization of side rails in a timely manner. Observations identified that the resident's bed had two half side rails up, contrary to the care plan. An interview with the DNS revealed that the care plan had not been revised since 2020 and lacked a physician's order.
The facility failed to provide a discharge transition plan for a resident discharged AMA. Despite the resident's severe cognitive impairment and need for assistance, the responsible party took the resident home without receiving a proper discharge plan, as confirmed by the RN and DON.
A resident with multiple diagnoses, including chronic pain syndrome, experienced a fall and later reported new hip pain. The nursing staff administered pain medication but did not reassess the resident, attributing the pain to the chronic condition. An x-ray was ordered but not obtained before the resident was transferred to the ER for an unrelated issue. Interviews revealed that the RN should have reassessed the resident, and the facility did not provide a policy for RN assessments.
A resident with multiple diagnoses and a moderate fall risk was left unattended in an unsafe position with a high bed, leading to a fall. The resident had reported a malfunctioning side rail, which was not addressed over the weekend. The facility's failure to ensure timely maintenance and appropriate supervision resulted in the resident's fall and transfer to an acute care facility.
The facility failed to communicate a resident's fall to the community center providing specialized services. The resident, who had multiple diagnoses including end-stage renal disease, fell out of bed and the incident was not documented in the communication book. This led to the specialized service center withholding heparin and transferring the resident to the Emergency Department post-treatment.
The facility failed to ensure timely review and follow-up of pharmacy recommendations for two residents. One resident had no follow-up on recommendations for alternative medications due to swallowing difficulties, and another resident had delayed action on a recommendation to evaluate and consider discontinuation of lorazepam PRN due to the lack of a stop date.
The facility failed to maintain accurate clinical records for two residents involved in an alleged physical mistreatment incident. A resident with dementia expressed pain when a nurse aide forcefully attempted to put them to bed, witnessed by another resident. The incident was not documented in the clinical records, contrary to facility policy.
The facility failed to ensure that PBJ data was complete and accurate for multiple quarters, identifying excessively low weekend staffing. The Administrator revealed that the data inputted automatically through payroll did not capture hours worked by agency or shared staff, and agency staff did not punch in. This issue had been fixed for 2024.
The facility's QAA committee meetings lacked the required attendance of the Medical Director and Infection Preventionist for three consecutive months. The Administrator and DNS confirmed that the Medical Director attends quarterly medical staff meetings instead, and the Infection Control Nurse does not attend QAPI meetings due to her part-time schedule.
Medication Administration Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, with the observed error rate identified as 6.9% during medication administration observation for one resident. Resident #127 had diagnoses including major depression, diabetes, heart failure, hypertension, and anemia, and the quarterly MDS identified intact cognition. The resident’s care plan directed staff to administer psychotropic medications as ordered by the physician, and the physician’s orders included Aspirin 81 mg daily, Plavix 75 mg daily, Cymbalta 60 mg, Abilify 10 mg daily, Losartan Potassium 25 mg daily, Singulair 10 mg daily, Steglatro 15 mg daily, Torsemide 20 mg twice daily, and Percocet 10-325 mg every 6 hours as needed. During observation of medication administration, an LPN removed medications from the cart, placed them in a cup, and administered Aspirin, Plavix, Losartan Potassium, Steglatro, Singulair, and Torsemide to the resident. When the resident requested pain medication, the LPN searched the cart and stated that Abilify and Cymbalta were not available and that she would need to check the medication room. The LPN and supervisor later removed Percocet 5-325 mg from the emergency box and the LPN administered one tablet to the resident. The LPN stated she completed the medication pass and moved on to the next resident. Review of the MAR showed the LPN signed off that Cymbalta 60 mg and Abilify 10 mg were administered at 9:00 AM, even though she later stated those medications had not been given because they were not in the medication cart. The LPN acknowledged she should not have documented them as given and stated she would not have returned to look for or administer them if the surveyor had not reconciled the MAR and identified the discrepancy. The MAR also did not show the Percocet 5-325 mg as administered in accordance with the physician’s order. The DNS stated nurses are required to administer medications as ordered and sign off only medications actually given, and that pain medication removed from the e-box must be documented on the MAR.
Incomplete MAR and TAR Documentation
Penalty
Summary
The facility failed to ensure the clinical record was accurate and complete for medication administration and wound care documentation. For one resident with diagnoses including neuromuscular dysfunction of the bladder, osteoarthritis, chronic deep vein thrombosis, and diabetes, the record showed multiple scheduled medications and sliding-scale insulin doses that were reportedly administered by an LPN on several shifts, but the MAR was not signed to reflect administration. The missed documentation included Tylenol, Eliquis, Vasotec, atorvastatin, insulin glargine, pregabalin, Pro-stat, and lispro on multiple dates and shifts. The DNS stated nurses must sign the MAR when medications are administered and that the charge nurse is responsible at the end of each shift for ensuring medications are administered and documented. The same resident’s wound care documentation was also incomplete. For another resident with peripheral vascular disease, severe protein-calorie malnutrition, generalized muscle weakness, and a quarterly MDS showing a BIMS score of 15/15, dependence for all ADLs, non-ambulatory status, and an unhealed stage 4 pressure ulcer, physician orders directed daily wound care to the left heel and left ischium. Review of the TAR showed that wound treatments were not signed off on multiple days by the nurses assigned to the resident’s care. One LPN stated she administered the treatments but did not sign because of computer issues and leaving early, and the ADNS stated she administered the treatments but forgot to sign the TAR. Facility interviews and policy review confirmed that documentation was expected at the time medications or wound treatments were administered. The medication administration policy required nurses to sign the MAR after administration, and the wound treatment policy directed that wound treatments be documented at the time of each treatment. The DNS could not explain why the MARs and TARs were not signed for the documented medication passes and wound treatments, despite staff stating the care had been provided.
Urinary Drainage Bag Left Visible Without Privacy Cover
Penalty
Summary
The facility failed to ensure Resident #2’s urinary drainage bag was maintained in a manner that protected privacy and dignity. Resident #2 had diagnoses including urgency of urination, neuromuscular dysfunction of the bladder, and diabetes, and the care plan identified the resident required an indwelling catheter due to neurogenic bladder. The care plan also included providing privacy and comfort, catheter care per physician orders and as needed, keeping the catheter off the floor, and providing a privacy bag. The physician ordered a 16 French foley catheter to bedside drainage with catheter care every day shift, every evening shift, and as needed, and to empty the drainage system at least every 8 hours and when it was 1/4 to 2/3 full. Observations on multiple occasions found the resident lying in bed with the urinary drainage bag attached to the right side foot portion of the bed frame and visible from the hallway without a privacy cover. On one observation, the drainage bag was approximately half full of yellow liquid. The ADNS observed the bag visible from the hallway and stated all urinary drainage bags must always be covered to protect residents’ dignity and privacy, and that if a privacy cover was missing, the nurse aide or charge nurse was responsible for obtaining one immediately. The DON also stated any resident with a urinary drainage bag must always have a privacy cover in place to maintain dignity and privacy. The facility’s catheter policy stated privacy bags would be available and catheter drainage bags would be covered while in use, and the Resident Rights policy identified the resident has the right to a dignified existence and self-determination.
Failure to Assess Self-Administration of Medication
Penalty
Summary
The facility failed to assess whether Resident #91 could safely self-administer medication. Resident #91 had diagnoses including hypertension, hepatitis C, kidney disease, and pruritus, and the care plan identified itching and a risk for decreased ability to perform ADLs. The admission MDS identified the resident as cognitively intact and needing supervision or touching assistance for toileting, standing/transferring, and bed mobility, and also noted the resident required application of ointments/medications other than to the feet. During observations, a 2-ounce tube of Hydrocortisone 1% cream was found on the resident’s bedside table and was not in its original box, did not have a pharmacy label, and did not show an opened date. The resident stated the cream was provided by nursing staff and routinely left at the bedside, and later stated the resident could not recall which staff member provided it or when it was given. The DNS confirmed the resident was keeping the cream at the bedside and that the clinical record did not reflect an assessment for self-administration of medications. The facility policy stated a resident may only self-administer medications after the interdisciplinary team determines which medications may be safely self-administered, and that the resident’s preferences and storage arrangements must be documented in the medical record.
Incomplete Advance Directives Documentation
Penalty
Summary
The facility failed to ensure an advance directives form was completed according to Resident #127’s expressed wishes. Resident #127 had diagnoses including Type 2 diabetes mellitus, congestive heart failure, and osteomyelitis. The Resident Care Plan identified the resident as having established advance directives and being Full Code, and a physician’s order also directed Full Code status. The quarterly MDS assessment showed a BIMS score of 15, indicating intact cognition. During record review and interviews, an unsigned and incomplete advance directives form was found in the resident’s paper chart, and there were no signed advance directives in either the paper chart or the EMR. An LPN stated the admitting nurse and RN supervisor were responsible for completing advance directive forms during admission. An RN manager stated that although the EMR showed Full Code, she could not confirm that this reflected the resident’s current wishes without a signed advance directive and said she would need to verify the resident’s preference. The DNS stated nurses are responsible for ensuring advance directives are completed for every resident on day of admission, but could not explain why Resident #127’s advance directives had not been completed.
Unclean resident room and soiled wheelchair
Penalty
Summary
The facility failed to ensure a resident with respiratory concerns had a clean and sanitary homelike environment. Resident #11 had diagnoses including chronic respiratory failure with hypoxia, tracheotomy, COPD, stroke, and a g-tube related to dysphagia. The quarterly MDS identified intact cognition and independence with ADLs. Physician orders directed enteral tube feeding via g-tube twice daily, tracheostomy care twice daily and as needed, and enhanced barrier precautions related to ESBL in tracheostomy secretions. The RCP identified a tracheostomy in place with interventions for tracheostomy care and tube changes per physician orders. Observations on multiple dates showed Resident #11 seated in a wheelchair in the room, and the wheelchair had visible dirt buildup on the seat, legs, and wheels, with the back right wheel torn and shredded. The room contained only a bed for seating and three rusty, soiled overbed tables used for meals, respiratory equipment, and computers. The walls and radiators had hardened brown drippings, the floor had brown spots and dirt built up along edges and corners, and a red rolling walker near the doorway was soiled with brown debris. During interview, the Administrator acknowledged dirt and food buildup on the floor and wheelchair, stated the room required deep cleaning, and was unable to explain why the wheelchair and room had not been cleaned. The Director of Housekeeping stated the room was scheduled for monthly deep cleaning but could not verify completion, could not locate wheelchair cleaning rosters, and could not verify whether the wheelchair had been washed in the last 6 months.
Failure to File Resident Grievance About Staff Treatment
Penalty
Summary
The facility failed to file a grievance for a resident who voiced concerns about treatment by a staff member. Resident #96 had diagnoses including overactive bladder, repeated falls, and congestive heart failure, and the annual MDS identified a BIMS score of 15, indicating intact cognition. The resident was dependent for toileting hygiene and chair/bed-to-chair transfers, and the RCP noted the resident required extensive assistance with ADLs, including assist of two with a mechanical lift, assist of two for bed mobility, and dependence with toileting. The RCP also identified the resident as resistive to care and fabricated stories, with interventions to provide consistent, trusted caregivers and a structured daily routine when possible. Resident #96 told staff that an aide on day shift did not treat him/her well, spoke in a rude tone, rolled her eyes from the hallway, and made the resident feel humiliated when requesting toileting assistance. The resident stated he/she had told several nurses about the aide's behavior and that the aide was not removed from the assignment, but declined to identify the aide by name because of fear of retaliation. LPN #4 stated the resident had voiced a grievance about not being treated kindly by an aide, but she did not report it to her supervisor or anyone else because she believed the resident would not talk to the supervisor if it were reported. The DNS stated she was unaware of the concerns until surveyor inquiry and said the complaint should have been completed when first voiced. Review of grievance forms found no grievance for Resident #96 regarding inappropriate staff behavior, despite the facility policy requiring staff to record verbal grievances and forward them to the Grievance Official as soon as practicable.
Failure to Update PASRR After New Psychiatric Diagnoses
Penalty
Summary
The facility failed to submit a request for a PASRR Level II screen after a resident developed new psychiatric diagnoses. Resident #8 had diagnoses that included paranoid personality disorder, anxiety, depression, and dementia. A PASRR Level 1 screen dated 5/24/24 identified no mental illness or dementia and approved the resident for LTC. A later Level 1 screen dated 6/26/24 identified anxiety and dementia, but did not identify paranoid personality disorder or depression, and indicated no additional screening was required unless the resident was suspected of having a serious mental illness or intellectual or developmental disability and exhibited a significant change in treatment needs. The clinical record showed that paranoid personality disorder was added on 6/24/24 and anxiety disorder was added on 6/27/24. The admission MDS identified severely impaired cognition and diagnoses of paranoid personality disorder, anxiety, depression, and dementia, and the resident received antipsychotic and antidepressant medications. Psychiatric evaluation and consultation notes dated 6/27/24, 7/8/24, and 7/17/24 documented evaluation for mood and behaviors related to insomnia, anxiety, depression, agitation, dementia, and paranoid personality disorder. The record did not show that the PASRR contracted agency was notified of the new psychiatric diagnoses from 6/27/24 through 2/9/26 for an additional Level 1 and Level 2 screen, and the Director of Social Services stated the resident's PASRR should have been resubmitted when the new diagnoses were identified.
Unsecured Hydrocortisone Cream Left at Bedside Without Order
Penalty
Summary
The facility failed to properly secure medication and failed to obtain a physician’s order before providing medication to Resident #91. Resident #91 had diagnoses including hypertension, hepatitis C, kidney disease, and pruritus, and the admission MDS identified the resident as cognitively intact and requiring assistance with some ADLs. The resident’s care plan noted itching and interventions to administer medications as ordered and document effectiveness. During observation on 2/5/26, a 2-ounce tube of Hydrocortisone 1% cream was found on the resident’s bedside table, not in its original box and without a pharmacy label or opened date. The resident stated nursing staff had provided the cream and routinely left it at the bedside. A review of the clinical record on 2/5/26 did not identify a physician’s order for Hydrocortisone 1% cream. After surveyor inquiry, a physician’s order was obtained for topical application to the trunk and bilateral arms every day and night shift for itch for 14 days. On 2/9/26, the cream was again observed on the bedside table, and the DNS stated it should not have been left there and identified it as facility house stock. The DNS also stated a physician order is required before administering any medications, including house stock. Facility policies required medications to be stored securely and administered only upon a signed order from an authorized prescriber.
Infection Control and EBP PPE Failures During Wound Care
Penalty
Summary
The facility failed to maintain proper infection control during wound care for a resident with severe protein-calorie malnutrition, osteoarthritis, colonized MRSA, and peripheral vascular disease. During observed wound care, the LPN placed a bottle of Dakins solution and supplies on the resident’s bedside table without first cleansing the surface or using a barrier. The LPN then removed soiled gloves and donned new gloves multiple times without performing hand hygiene between glove changes. The LPN also used the same gauze and calcium alginate with silver in a manner that required intervention by the ADNS, who directed the LPN to remove the gauze from the wound bed and apply the calcium alginate with silver correctly. The resident had a stage 4 pressure ulcer and additional wounds to the left heel and right heel, and the wound care was performed while the resident was dependent on staff for all ADLs. The facility also failed to ensure appropriate PPE use for a resident with a stage 2 pressure ulcer and severe cognitive impairment who was identified as being on Enhanced Barrier Precautions. Although an EBP sign was posted outside the room directing staff to wear gown and gloves for high-contact activities, a NA began rolling the resident in preparation for wound care and incontinent care without wearing a gown or gloves. The NA stated that gown and gloves should have been worn but she did not think of it. The resident’s care plan did not identify EBP, and the physician’s order record initially did not include an order directing EBP until after surveyor inquiry. A second resident with diabetes, congestive heart failure, osteomyelitis, intact cognition, and moisture-associated skin damage to the buttocks was also identified as being on EBP by signage outside the room. The ADNS provided wound care to this resident without wearing a gown, stating she felt rushed and had many medications to pass. Interviews with nursing leadership confirmed that staff should wear appropriate PPE for residents on EBP during hands-on care, including wound care and incontinence care, and that the NA and ADNS should have donned the required PPE before providing care.
Failure to Treat Resident with Respect and Dignity During Verbal Exchange
Penalty
Summary
A deficiency occurred when a resident with a history of depressive episodes, anxiety, delusional disorders, and auditory hallucinations was not treated with respect and dignity during an interaction with a nurse aide (NA). The resident, who required assistance with activities of daily living (ADLs) and had a BIMS score of 13/15, became upset during an incident involving spilled food. Witnesses reported that the NA spoke to the resident in a loud and harsh manner, questioning the resident's ability to clean themselves and using inappropriate language. The resident responded with foul language, and the NA repeated the phrase back to the resident, further escalating the situation. Multiple staff members, including a dietary aide and an LPN, overheard the exchange and confirmed that the NA's tone and volume were inappropriate. Facility documentation and interviews indicated that the NA's conduct did not align with the facility's policies on resident rights and professional behavior. The NA engaged in a verbal exchange with the resident, raising her voice and repeating the resident's foul language, rather than de-escalating the situation or maintaining professionalism. The incident was reported to supervisory staff, who acknowledged that the NA's actions were unprofessional and did not uphold the resident's right to be treated with respect and dignity.
Failure to Prevent Elopement Due to Inadequate Supervision and Alarm Response
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment, a history of wandering, and a documented risk for elopement was able to exit the facility unsupervised. The resident had diagnoses including metabolic encephalopathy, alcohol-induced dementia, and anxiety, and required supervision for activities of daily living. The care plan and risk assessments identified the resident as being at moderate risk for elopement, with interventions such as a wander guard bracelet and visual checks every 1-2 hours. Despite these measures, the resident was able to leave the building without staff knowledge. On the day of the incident, the resident was last seen in the hallway, and shortly after, the emergency exit door alarm sounded. A nurse aide responded to the alarm, reset it, but did not investigate the cause or check outside to see if anyone had exited. The nurse aide was unaware that the alarm required further investigation, despite having received prior education on the policy. The resident was not located during subsequent checks, and staff did not immediately follow the facility's elopement protocol, such as initiating a facility-wide search or alerting the appropriate personnel in a timely manner. The resident was eventually found by police at a nearby facility, having complained of chest pain and requiring emergency department evaluation. Interviews with staff revealed gaps in knowledge and execution of elopement protocols, including failure to investigate door alarms and delays in notifying supervisors and initiating search procedures. The emergency exit door in question was not equipped with a wander guard alert system, and staff responses did not align with facility policy for elopement prevention and management.
Failure to Implement and Document Wanderguard Use for Resident with Wandering Behavior
Penalty
Summary
The facility failed to ensure that a resident with a known history of wandering had appropriate physician's orders and a care plan in place for a wanderguard, as required by facility policy. The resident was admitted with diagnoses including metabolic encephalopathy, alcohol-induced dementia, and anxiety, and was identified as having moderately impaired cognition and requiring assistance with activities of daily living. Despite multiple nursing and psychiatric notes documenting the resident's wandering behavior and the use of a wanderguard, there was no evidence in the medical record of an elopement assessment, progress note, or care plan addressing the use of the wanderguard prior to the resident's elopement event. Staff interviews revealed uncertainty regarding when the wanderguard was initially placed on the resident and a lack of documentation for the required physician's order, elopement assessment, and care plan updates. The facility's own policies directed that residents at risk for elopement should have care plans indicating such risk, with detailed monitoring interventions, and that the use of a wanderguard should be supported by physician orders and documented checks for functionality. However, these steps were not completed prior to the resident's elopement. The deficiency was further highlighted when the resident was found missing from their room and later located wandering outside the facility, requiring police and hospital involvement. Only after this incident was a physician's order for the wanderguard documented, and the care plan updated to reflect the resident's elopement risk and necessary interventions. Prior to the event, the lack of proper assessment, documentation, and care planning failed to address the resident's known wandering behavior and elopement risk.
Food Storage and Handling Deficiencies Noted in Dry Storage and Ice Machine Maintenance
Penalty
Summary
The facility failed to ensure proper food storage practices in the dry storage area, as observed during the survey. This included finding an open bag of chocolate chips, detergent bottles, and scrub pads stored alongside food items. Additionally, there was a lack of consistent documentation of daily food meal temperatures, with missing entries noted in the temperature logs. The report also highlighted instances of improper food handling, such as a cook using bare hands to handle hamburger rolls during plating, contrary to recommended food safety practices. Furthermore, observations revealed issues with the maintenance of ice machines, with pink debris buildup noted on the ice outlet and water overflow from the machines onto the floor. The maintenance director attributed the buildup to improper use of ice containers with juice residue. The report also pointed out deficiencies in cleaning practices, as evidenced by wet floors in the nourishment room and the need for manual emptying of ice machine catch trays to prevent overflow. Housekeeping procedures were found to be lacking, with staff unsure of the frequency of tray emptying.
Failure to Obtain Consent and Physician's Orders for Bed Rails
Penalty
Summary
The facility failed to acquire consent and physician's orders prior to the initiation of bed rails for six residents. For Resident #27, the facility did not obtain the necessary consents and physician's orders upon admission, only doing so after surveyor inquiry. Similarly, Resident #28 had bed rails in place without prior consent or physician's orders, which were only obtained after the surveyor's inquiry. Resident #34 also had bed rails without the required documentation, and the bed rail inspection was outdated, with the last inspection being over a year old before a new inspection was conducted after surveyor inquiry. Resident #87 had bed rails in place without documented consent or physician's orders, and the bed rail inspection was not updated annually as required. The Director of Maintenance admitted to not having completed the inspection since the previous year. Resident #212 had bed rails in place without any indication for use or consent obtained, and Resident #215 had bed rails without consent, with the last inspection being outdated by over a year. The facility's policy required annual inspections and obtaining consent and physician's orders, which were not followed. Interviews with the Director of Nursing Services (DNS), Director of Operations, and the Medical Director revealed that they were unaware of the lapses in obtaining consents and physician's orders for bed rails. The facility's policy directed that upon admission, each resident would be assessed for the need for bed rails, consent/education would be obtained prior to installation, and maintenance staff would complete an annual review of the condition and conduct any necessary maintenance. These steps were not followed, leading to the deficiencies identified by the surveyors.
Failure to Reflect Dementia Diagnosis and Facial Hematoma in Care Plans
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of dementia was properly reflected in the resident's care plan. Resident #28, who had diagnoses of dementia and Alzheimer's disease, exhibited behaviors such as yelling and striking out at staff and was resistant to care. The care plan dated 3/11/2024 did not mention dementia or Alzheimer's disease, despite the Minimum Data Set (MDS) assessment identifying cognitive loss. Interviews with RN #4 and RN #3 confirmed that the care plan did not reflect the dementia diagnosis and that it was the responsibility of the MDS Coordinator and nurses to update care plans as needed. A care plan addressing dementia was only added after the deficiency was identified during the survey on 4/2/2024. Additionally, the facility failed to develop a care plan for a facial hematoma present on admission for Resident #212. The resident, who had diagnoses including heart failure and diabetes mellitus, was admitted with a facial hematoma and a physician's order to monitor the area every shift. However, the care plan dated 3/22/2024 did not include the hematoma, despite the presence of a physician's order and the identification of the hematoma in the electronic record. Interviews with the ADNS and RN #4 confirmed that the care plan should have included the hematoma, and it was the responsibility of the MDS Coordinator and nurses to update care plans as needed. The facility did not provide a policy for baseline care plans when requested.
Failure to Revise Care Plan for Side Rail Utilization
Penalty
Summary
The facility failed to revise the care plan for a resident with dementia and Alzheimer's disease regarding the utilization of side rails in a timely manner. The resident's care plan, dated 3/11/2024, indicated that the bed should be kept in a low position and the side rails tied down to prevent the resident from putting their arms through the rails. However, observations on 4/3/2024 and 4/4/2024 identified that the resident's bed had two half side rails up. An interview and record review with the Director of Nursing Services (DNS) on 4/4/2024 revealed that the care plan intervention for side rails had not been revised since 2020 and did not include an indication for use or a physician's order.
Failure to Provide Discharge Transition Plan for AMA Discharge
Penalty
Summary
The facility failed to ensure a discharge transition plan was provided to the responsible party for a resident who was discharged Against Medical Advice (AMA). Resident #104, who had diagnoses including cerebral vascular disease and mild cognitive impairment, was identified as severely cognitively impaired and required moderate assistance with toileting. On the day of discharge, the responsible party decided to take the resident home, and the family signed the resident out AMA. Although medication and instructions were provided, a discharge transition plan was not discussed or provided to the family, as confirmed by the Registered Nurse (RN) on duty and the Director of Nursing (DON). The facility's policy for AMA discharges requires that a discharge transition plan be provided to the resident or their representative, including community referrals and documentation of the discharge process. However, in this case, the RN on duty did not recall discussing the discharge plan or living arrangements with the responsible party, nor did he provide a discharge transition plan. This failure to follow the facility's policy resulted in a deficiency in the discharge process for Resident #104.
Failure to Reassess Resident After Fall
Penalty
Summary
The facility failed to ensure that a resident reporting new pain following a recent fall was properly assessed. Resident #87, who had diagnoses including end-stage renal disease, hypertension, chronic pain syndrome, anxiety, and morbid obesity, experienced a fall on 3/18/24. Despite being identified as at moderate risk for falls and having a care plan in place, the resident was not reassessed for pain after the fall. Initially, no injuries or pain were noted, but later, during an occupational therapy session, the resident reported increased right hip pain. The nursing staff administered pain medication, but the resident was not reassessed by the RN on duty, who attributed the pain to the resident's chronic condition. An x-ray was ordered but could not be obtained before the resident was transferred to the Emergency Department for an unrelated issue. Interviews with the nursing staff and the Director of Nursing Services revealed that the RN on duty should have reassessed the resident following the report of new pain. The Advanced Practice Registered Nurse also confirmed that the new pain was different from the resident's chronic pain and warranted further assessment. The facility did not provide a policy for RN assessments when requested, highlighting a gap in their procedures for handling such incidents. This failure to reassess the resident's new pain following a fall constitutes a deficiency in the care provided by the facility.
Failure to Prevent Accident Hazard Leading to Resident Fall
Penalty
Summary
The facility failed to prevent an accident hazard for a resident who sustained a fall after being left in an unsafe position with the bed in a high position. Resident #87, who had diagnoses including end-stage renal disease, hypertension, chronic pain syndrome, anxiety, and morbid obesity, was identified as being at moderate risk for falls. Despite this, the resident was left unattended on their left side with the bed in a high position, leading to a fall. The resident had previously reported a malfunctioning side rail, which was not addressed over the weekend, contributing to the incident. On the day of the fall, a nurse aide (NA #2) left Resident #87 in an unsafe position to report a skin integrity issue and the broken side rail to the nurse. During this time, the resident rolled out of bed and fell. The Director of Maintenance was not notified of the broken rail over the weekend, and the rail was only fixed on the morning of the fall. Interviews with staff revealed that the bed rail was in a fixed down position and the bed was in a high position at the time of the fall. The Director of Nursing (DNS) and other staff members acknowledged that the resident should not have been left in an unsafe position and that proper notifications regarding the malfunctioning equipment were not made. The facility's failure to ensure timely maintenance and appropriate supervision resulted in the resident's fall and subsequent transfer to an acute care facility. The incident highlighted lapses in communication and adherence to safety protocols within the facility.
Failure to Communicate Resident Fall to Specialty Service Center
Penalty
Summary
The facility failed to ensure that a recent fall experienced by a resident was communicated to the community center providing specialized services. Resident #87, who had diagnoses including end-stage renal disease, hypertension, chronic pain syndrome, anxiety, and morbid obesity, fell out of bed on 3/18/24 after being positioned on their left side by a nurse aide. The fall was noted in the nurse's notes, but there was no documented communication to the Specialty Service Center regarding the incident. This lack of communication led to the resident reporting the fall and a head strike to the specialized service center, which subsequently withheld heparin and transferred the resident to the Emergency Department post-treatment. Interviews with the Licensed Practical Nurse and the Director of Nursing Services revealed that the nursing staff did not document the fall in the communication book that accompanies the resident to the community center. The facility's policy for Specialized Treatment Communication Form directs staff to ensure the completion of the communication form to coordinate care between the center and the facility. The failure to document and communicate the fall represents a deficiency in the facility's adherence to its own policies and procedures, potentially compromising the resident's care and safety.
Failure to Ensure Timely Review and Follow-Up of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure timely review and follow-up of pharmacy recommendations for two residents. For Resident #27, who had diagnoses including COPD, dementia, and bipolar disorder, a pharmacy note dated 6/26/23 recommended alternative medications for divalproex and pantoprazole due to swallowing difficulties and clarifying administration directions for potassium chloride. However, there was no physician response or follow-up on these recommendations. The DNS confirmed the absence of follow-up for the Drug Regimen Review dated 6/26/23 and could not provide a reason for the missing follow-up. For Resident #28, who had diagnoses including dementia, Alzheimer's disease, and delusional disorders, a pharmacy consultant document dated 11/28/23 recommended evaluating and considering discontinuation of lorazepam PRN due to the lack of a stop date, as per CMS guidelines. This recommendation was not addressed timely, resulting in a second recommendation on 1/30/24. The DNS could not explain why the initial recommendation was not addressed, leading to a delay in action. The facility's policy indicated that pharmacy recommendations should be acted upon within 10 working days, which was not adhered to in these cases.
Failure to Document Alleged Physical Mistreatment Incident
Penalty
Summary
The facility failed to maintain a complete and accurate clinical record for two residents involved in an alleged physical mistreatment incident. Resident #156, who had dementia and muscle weakness, was identified as severely cognitively impaired and required assistance with activities of daily living. Resident #159, who had an aneurysm of the artery of the lower extremity, was moderately cognitively impaired and required assistance with bed mobility and transfers. On the evening of 11/2/22, Resident #159 allegedly witnessed a nurse aide, NA #3, forcefully attempting to put Resident #156 to bed against their will, causing Resident #156 to express pain. This incident was reported, and NA #3 was removed from the building pending investigation. However, there was no documentation of this incident in the clinical records of either resident. An interview with RN #2, who was the nursing supervisor on duty during the incident, confirmed that she was notified of an altercation and observed Resident #159 kicking NA #3, who was holding Resident #159's wrists to prevent further assault. RN #2 intervened and learned that Resident #159 had concerns about the care provided to Resident #156. A skin check was conducted for Resident #156, and the Director of Nursing Services (DNS) was notified. Both RN #2 and the DNS acknowledged that the incident should have been documented in the clinical records of both residents, as per the facility's policy for charting and documentation.
Incomplete and Inaccurate PBJ Data Submission
Penalty
Summary
The facility failed to ensure that Payroll Based Journal (PBJ) data was complete and accurate for Quarter 4 of 2023, Quarter 3 of 2023, Quarter 2 of 2023, and Quarter 1 of 2023. The PBJ submissions for these quarters identified excessively low weekend staffing. An interview with the Administrator revealed that the data for the PBJ is inputted automatically through payroll, and the facility did not capture the hours worked by agency or shared staff. Additionally, the Administrator indicated that agency staff do not punch in, and this issue had been fixed for 2024. A review of the facility policy for Nursing Services and Sufficient Staff identified that the facility is responsible for submitting timely and accurate staffing data through the CMS Payroll-Based Journal system.
Failure to Include Required Members in QAA Committee
Penalty
Summary
The facility failed to have a Quality Assessment and Assurance (QAA) committee consisting of the minimum required members. The QAPI meeting sign-in sheets for three consecutive months identified the attendance of the Administrator, Director of Nursing Services (DNS), and other staff members, but the Medical Director and Infection Preventionist were not in attendance. During an interview, the Administrator and DNS confirmed that the Medical Director does not attend the monthly QAPI meetings but attends the quarterly medical staff meetings, which are different from the QAPI meetings. Additionally, the Infection Control Nurse, who is a corporate nurse and works at the facility three days a week, does not attend the QAPI or medical staff meetings as they occur on Fridays, a day she does not work.
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What surveyors actually found near you
We read the 798 citations issued within 25 miles in the last 12 months — including the 11 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
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Meriden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Connecticut Baptist Homes, Inc | 1.3 mi | ★★★★★ | 9 | 0 |
| Apple Rehab Coccomo | 1.8 mi | ★★★★★ | 0 | 0 |
| Silver Springs Care Center | 1.9 mi | ★★★★★ | 4 | 0 |
| Curtis Home St Elizabeth Center, The | 2 mi | ★★★★★ | 0 | 0 |
| Meriden Health And Rehab | 2.2 mi | ★★★★★ | 5 | 0 |
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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.