Above 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 Essex Meadows Health Center during CMS and state inspections, most recent first.
A resident with a history of falls and cognitive impairment developed increased pain and swelling in the left hip following a fall, but staff delayed both assessment and provider notification. Despite clear signs of a change in condition, including pain, swelling, and decreased mobility, nursing staff did not promptly notify the provider or follow up when there was no immediate response. An x-ray eventually revealed acute pelvic fractures, but only after a significant delay in communication and intervention.
A resident with dementia and a history of falls was not thoroughly assessed after a fall, despite developing significant pain and swelling in the hip. Nursing staff delayed both assessment and provider notification, and communication between shifts was inconsistent. An x-ray later revealed pelvic fractures, confirming that required protocols for post-fall assessment and change of condition notification were not followed.
The facility failed to notify a provider of a medication omission for a resident with a UTI and did not notify providers of significant weight changes for two residents, one with CHF and another with chronic conditions. The facility's policies required provider notification for these issues, but documentation and staff awareness were lacking.
A resident reported inappropriate touching by a nurse aide during personal care, but the facility failed to report the abuse allegation to the State Agency within the required 2-hour timeframe. The DNS delayed reporting due to uncertainty about the resident's consistency in maintaining their allegations, despite facility policy requiring immediate notification.
A facility failed to administer a PRN diuretic for a resident with CHF despite weight gain exceeding parameters, due to staff unawareness of the order. Additionally, weekly skin assessments for another resident at risk for skin integrity issues were not completed for three weeks, possibly due to a new charting system. These deficiencies indicate issues in communication and documentation practices.
A facility failed to follow its policy for monitoring a resident's weight, leading to a deficiency in nutritional care. The resident, with conditions like diabetes and chronic kidney disease, showed a significant weight discrepancy upon admission, which was not addressed with required reweighing or documentation. Weights were inaccurately recorded and later struck out, and the facility did not document necessary interventions for a significant weight increase, failing to maintain the resident's health.
A resident with a confirmed UTI experienced a delay in starting antibiotic treatment due to the unavailability of the prescribed ciprofloxacin 500 mg in the Omnicell. Although ciprofloxacin 250 mg capsules were available, the RN was unaware and did not administer them. The provider was not notified of the medication's unavailability, leading to a delay of over 17 hours before treatment began.
A facility failed to implement a 14-day stop date for a PRN antipsychotic medication, prochlorperazine maleate, prescribed to a resident with a history of malignant neoplasm and severe sepsis. The medication was administered seven times beyond the required period without a stop date recommendation from the consultant pharmacist, who acknowledged the oversight during a review.
A resident with Alzheimer's and a history of exit-seeking behaviors, who required a wander guard device, was able to leave the facility unsupervised when the wander guard alarm failed to sound. The resident was found outside by security, despite care plan interventions and required checks of the device, resulting in a deficiency related to accident hazard prevention and supervision.
Failure to Immediately Notify Provider of Resident's Change in Condition After Fall
Penalty
Summary
A deficiency occurred when the facility failed to immediately notify the provider after a resident developed swelling and increased pain in the left hip following a fall that had occurred two days prior. The resident, who had a history of dementia, muscle weakness, unsteadiness, repeated falls, and osteopenia, was identified as a high fall risk. After the fall, the initial post-fall assessment did not include a check of the range of motion or rotation of extremities, and although the family and provider were notified of the fall, no new orders were documented and the resident was not transferred for further evaluation at that time. Over the next two days, the resident exhibited signs of increased pain, swelling, and difficulty with mobility and eating, as observed by nurse aides and nursing staff. Despite these changes, there was a delay in both the assessment by a registered nurse and in notifying the provider of the resident's worsening condition. The LPN on duty documented the findings several hours after being notified and only sent a text message to the provider, without receiving a timely response. The RN who was informed of the resident's pain and abnormal behavior did not assess the resident or notify the provider as required. The provider was eventually notified of the resident's increased pain and swelling, but there was a significant delay before an order for an x-ray was obtained and completed. The x-ray revealed acute, mildly displaced fractures of the left pelvis. Facility policy required prompt assessment and provider notification for changes in condition, but this was not followed, resulting in delayed medical intervention for the resident.
Failure to Assess and Notify Provider After Resident Fall Resulting in Fracture
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, muscle weakness, unsteadiness, pain, and repeated falls was not properly assessed following a fall. The resident, identified as a high fall risk with a care plan in place for mobility assistance and safety interventions, experienced a fall after attempting to self-ambulate. The initial post-fall evaluation documented a head injury and a skin tear but did not include a thorough assessment of the extremities, specifically omitting range of motion or rotation checks. Although the family and provider were notified, no new orders were issued at that time. In the days following the fall, the resident exhibited increased pain, swelling, and edema in the left hip, with pain scores escalating to eight out of ten. Despite these symptoms, documentation failed to show that a focused assessment of the left hip was conducted immediately. Nursing staff delayed notifying the provider and did not document their findings promptly. Communication between shifts was inconsistent, with nurse aides and LPNs reporting pain and functional decline, but the responsible RN did not assess the resident or notify the provider as required by facility policy. The resident's condition continued to deteriorate, with ongoing pain, refusal to eat, and difficulty with mobility. Eventually, an x-ray revealed acute, mildly displaced fractures of the left pelvis. Interviews confirmed that staff recognized abnormal pain and behavior but did not follow established protocols for assessment and provider notification. Facility policy required prompt assessment and notification for changes in condition, which was not followed in this case.
Failure to Notify Provider of Medication Omission and Significant Weight Changes
Penalty
Summary
The facility failed to notify a provider of a medication omission for a resident with a urinary tract infection (UTI). Resident #8, who was admitted with diagnoses including cellulitis, congestive heart failure (CHF), and UTI, was prescribed ciprofloxacin for the UTI. However, a nursing progress note indicated that the medication was not available for administration, and the provider was not notified of this omission, contrary to the facility's policy on physician's orders. Additionally, the facility did not notify a provider of significant weight changes for Resident #8, who was at risk for fluid overload due to CHF. The resident experienced multiple instances of weight gain that met the criteria for provider notification as per the facility's policy and the resident's care plan. Despite this, there was no documentation of provider notification for these weight changes, and the nursing staff were unaware of the specific parameters for reporting weight changes outlined in the PRN order for bumetanide. Furthermore, the facility failed to notify a provider of significant weight changes for Resident #36, who was admitted with conditions including hypertension and chronic kidney disease. The resident experienced a significant weight loss and subsequent weight gain, but there was no documentation of provider notification. The facility's policy required reweighing and notification of significant weight changes, but these actions were not documented. The discrepancies in weight documentation and lack of adherence to the facility's weight policy contributed to the deficiency.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the State Agency within the required 2-hour timeframe. The incident involved a resident who was cognitively intact and required assistance with daily activities. The resident reported to a registered nurse that a nurse aide had touched them inappropriately during personal care. The allegation was documented, and the resident requested that the nurse aide no longer provide care. Despite the report being made to the facility staff, the Director of Nursing Services (DNS) delayed reporting the incident to the State Agency, citing uncertainty about the resident's consistency in maintaining their allegations. The facility's policy mandates immediate reporting of abuse allegations to the Administrator and the State Department of Health within 2 hours if the alleged violation involves abuse. However, the DNS did not report the incident to the State Agency until several days later. Interviews with facility staff confirmed the delay in reporting and highlighted that the DNS was aware of the requirement but chose to wait due to the resident's history of recanting allegations. This inaction led to a deficiency in the facility's compliance with state regulations regarding the timely reporting of abuse allegations.
Failure to Administer PRN Medication and Complete Skin Assessments
Penalty
Summary
The facility failed to administer a PRN medication according to provider orders for a resident with congestive heart failure (CHF). The resident, who was admitted with diagnoses including cellulitis, CHF, and dementia, had a care plan that included monitoring for fluid overload and administering diuretics as ordered. Despite a provider order for a PRN dose of bumetanide if the resident's weight increased by 2 lbs. in one day or 5 lbs. in one week, the facility did not administer the medication on several occasions when the resident's weight exceeded these parameters. Interviews with nursing staff revealed a lack of awareness of the PRN order, and the facility's CHF policy did not include directions for medication management of weight gain. The facility also failed to complete preventative weekly skin assessments for a resident at risk for skin integrity issues. This resident, admitted with conditions including hypertension, chronic kidney disease, and dermatophytosis, required weekly skin assessments as per physician orders. However, documentation showed that these assessments were not completed for three consecutive weeks. Interviews with nursing staff and the Director of Nursing Services (DNS) indicated that the facility had recently transitioned to a new charting system, which may have contributed to the missed assessments. The facility's failure to adhere to provider orders and complete required assessments highlights deficiencies in communication and documentation practices. The lack of awareness among nursing staff regarding PRN medication orders and the incomplete skin assessments suggest systemic issues in the facility's processes for managing resident care and ensuring compliance with care plans and physician orders.
Failure to Monitor Resident's Weight and Nutrition
Penalty
Summary
The facility failed to adhere to its policy for obtaining and documenting weights for a resident, leading to a deficiency in monitoring the resident's nutritional status. The resident, admitted with conditions including hypertension, chronic kidney disease, and diabetes, was discharged from the hospital with a weight of 199 pounds. However, upon admission to the facility, the resident's weight was recorded as 181.2 pounds, indicating a significant weight loss of 17.8 pounds. Despite this discrepancy, the facility did not reweigh the resident as required by their policy. Additionally, the resident was not weighed weekly for four weeks post-admission, as stipulated by the facility's weight policy. The deficiency was further compounded by the inaccurate documentation of weights on 10/30/24 and 11/14/24, which were later struck out by a registered nurse due to perceived inaccuracies. The facility's Director of Nursing Services (DNS) and other staff were unable to provide explanations for the lack of reweighing or the failure to document interventions following a significant weight increase to 226.2 pounds by 12/2/24. The facility's policy required reweighing and notifying the dietician, physician, and family in the event of significant weight changes, but these actions were not documented or carried out, leading to a failure in maintaining the resident's health through proper nutritional monitoring.
Delayed Antibiotic Administration for UTI
Penalty
Summary
The facility failed to timely start treatment for a resident with a confirmed urinary tract infection (UTI). The resident, who was admitted in December 2024, had a history of cellulitis, dementia, and congestive heart failure. On December 31, 2024, a provider ordered a urinalysis with culture and sensitivity due to the resident's complaint of dysuria. The laboratory results on January 6, 2025, confirmed a UTI and recommended ciprofloxacin as an effective treatment. However, the first dose of ciprofloxacin was not administered until January 7, 2025, more than 17 hours after the order was received. The delay in administering the antibiotic was due to the medication not being available in the Omnicell in the required dosage of 500 mg. Although ciprofloxacin 250 mg capsules were available, RN #7 did not administer them, as she was unaware of their availability. The Director of Nursing Services (DNS) confirmed that the 250 mg capsules were in stock and could have been used. Additionally, the provider was not notified of the unavailability of the medication, contrary to the facility's policy. RN #7 resigned without notice after the shift on January 6, 2025, and the provider was only informed of the delay the following day.
Failure to Implement 14-Day Stop Date for PRN Antipsychotic Medication
Penalty
Summary
The facility failed to implement a 14-day stop date for an as-needed antipsychotic medication, prochlorperazine maleate, prescribed to a resident. The resident, who was admitted in November 2024, had a history of malignant neoplasm, severe sepsis with septic shock, and generalized anxiety disorder. The medication was ordered on 11/29/2024 for nausea and vomiting, but the pharmacy consultation report dated 12/29/2024 did not include a recommendation for a 14-day stop date, as required for as-needed antipsychotic medications. The resident's administration record showed that the medication was administered seven times beyond the 14-day period from the initial order date. During an interview on 1/10/2025, the consultant pharmacist acknowledged the oversight and stated that the medication order was missed during the review. The facility's psychoactive drug management policy mandates monthly pharmacy reviews to ensure appropriate medication management, including the implementation of stop dates for as-needed antipsychotic medications.
Failure to Prevent Elopement Due to Non-Functioning Wander Guard Alarm
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, anxiety, restlessness, and agitation, who was identified as an elopement risk and required a wander guard bracelet, was able to exit the facility unsupervised. The resident's care plan included interventions such as a wander guard in place, quarterly elopement assessments, and monitoring for exit-seeking behaviors. Despite these measures, the resident was found outside in the parking lot late at night, fully dressed and seated in a wheelchair, by a security guard. The wander guard device was in place on the resident's ankle, but the alarm did not sound when the resident exited through the doors. Clinical documentation showed that the functionality of the wander guard was last checked the previous day, and its placement was checked earlier on the day of the incident. Staff interviews confirmed that the alarm was not heard and that the resident was able to leave the building undetected. The facility's policy required daily checks of the wander guard system and placement verification every shift, but the failure of the alarm system allowed the resident to exit unsupervised, resulting in a deficiency related to accident prevention and adequate supervision.
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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 Essex
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gladeview Health Care Center | 2.8 mi | ★★★★★ | 1 | 0 |
| Apple Rehab Saybrook | 3 mi | ★★★★★ | 5 | 0 |
| Aaron Manor Nursing & Rehabilitation | 5.6 mi | ★★★★★ | 0 | 0 |
| Bride Brook Rehabilitation & Nursing Center | 8.5 mi | ★★★★★ | 0 | 0 |
| Chestelm Health And Rehabilitation Center | 10.5 mi | ★★★★★ | 2 | 0 |
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