Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Apple Rehab Mystic during CMS and state inspections, most recent first.
The facility failed to supervise smoking activity, maintain shower equipment, and ensure wheelchair footrests were in place. A resident with severe cognitive impairment fell when a shower chair collapsed and sustained a skin tear, while another resident with nicotine dependence was found with cigarettes and a lighter and had repeated smoking-related incidents without documented A&I follow-up. A third resident who depended on staff for wheelchair mobility slid from a wheelchair when the leg rests were not in place, and staff confirmed the resident needed the supports while seated and transported.
Failure to timely notify MD/APRN of bruising of unknown origin. A resident with dementia, anxiety, and osteoarthritis had severe cognitive impairment, required extensive assistance with ADLs, and had no prior skin problems. Staff observed bruising on both forearms, but the nursing record did not document timely MD/APRN notification, and the APRN stated she was not informed until several days later. Interviews confirmed the MD/APRN should have been notified when the bruising was first identified.
Failure to thoroughly investigate bruising of unknown origin. A resident with severe dementia and total dependence for many ADLs developed bilateral forearm bruising, and staff initially noted no pain, no known cause, and no witnesses. Later documentation described the bruises as dark red to maroon, and the DNS and ADNS acknowledged that staff statements were not obtained when the bruises were first found and that the incident was not fully investigated at that time.
Incomplete Bruise Assessment and Delayed Surgical Wound Treatment: The facility failed to fully assess bruising of unknown origin on one resident with dementia and severe functional dependence, as the initial documentation lacked key details and the RN did not notify the APRN/MD when the bruises were found. The facility also delayed surgical wound care for another resident after hospital discharge instructions for daily Xeroform/Kerlix/ACE wrap treatment were not entered into orders on readmission, and the first documented wound treatment occurred several days later.
A resident with a history of bipolar disorder and moderate cognitive impairment engaged in a verbal altercation with another resident, including threats of physical violence. Multiple staff members documented the incident, but the DON was not informed, resulting in a 51-day delay in reporting the abuse allegation to the State Agency as required by facility policy.
Nine residents on precautions for MDROs did not have trash receptacles positioned inside their rooms for proper PPE disposal, as required by CDC guidance. Staff reported a shortage of trash cans and admitted to discarding PPE in bathrooms or hallway trash bins. The infection control nurse had not performed required spot checks, and the facility's EBP policy lacked guidance on trash can placement and monitoring adherence.
The facility did not update care plans with new interventions after the discovery of new or worsening skin impairments in three residents with complex medical histories, including wounds and pressure ulcers. Despite documentation of ongoing skin issues and nursing notes indicating care plan updates, reviews showed that care plans were not revised for extended periods, contrary to facility policy and staff expectations.
Three residents with significant risk factors for skin breakdown did not receive weekly skin assessments as ordered by physicians, resulting in missed documentation and delayed identification of wounds, including pressure ulcers and diabetic wounds. Nursing staff failed to consistently perform and document required weekly body audits, despite facility policy and physician directives.
A resident with chronic pain and a terminal illness died, but their prescribed narcotic medication (Dilaudid) was not removed from the medication cart for 20 days. Staff interviews revealed that narcotics were not consistently removed in a timely manner after residents were discharged or expired, and that required co-signatures and removal procedures were not followed according to facility policy.
A resident with memory deficits and depression left the facility without staff knowledge and was later found by police at a nearby location. The facility failed to perform quarterly elopement risk assessments as required by its policy, both for this resident and for additional residents, resulting in missed identification of elopement risk.
The facility failed to review and obtain advance directives and code status for three residents upon admission. One resident with alcoholic cirrhosis and another with osteomyelitis experienced delays in completing Medical Interventions Consent forms and physician's orders for code status, which were not documented until several days after admission. A third resident with syncope and brain neoplasm also faced similar delays. The facility's policy requires these directives to be reviewed and documented upon admission, but this was not followed.
A facility failed to ensure proper medication administration and storage. A resident was found with expired nasal spray at the bedside without evaluation for self-administration. Additionally, two residents received medications without proper identification checks by LPNs, contrary to facility policy requiring the use of identifiers.
The facility failed to conduct proper neurological assessments for two residents after unwitnessed falls, did not administer an anxiolytic medication as ordered for a resident with mental health issues, and lacked a physician's order for a resident's indwelling catheter. These deficiencies highlight lapses in following facility policies and protocols.
A resident with chronic health issues and a history of falls experienced multiple unwitnessed falls due to inadequate supervision and delayed updates to their care plan. Despite being at high risk, the facility failed to implement timely interventions after each fall, leaving the resident unsupervised in areas not visible from the nurse's station. The facility's policy required care plan updates after each fall, but this was not consistently done.
A resident with CHF and other medical conditions was not weighed daily as ordered by the physician, resulting in an unmonitored weight loss of 8.5 pounds. Facility staff were unaware or did not communicate the missed weights, leading to a deficiency in care.
The facility failed to maintain accurate records for controlled drugs brought in by two residents from an outside pharmacy. The DNS's office, where discontinued drugs were stored, was found unsecured, and the key to the cabinet was easily accessible. Tramadol and Clonazepam lacked proper reconciliation forms, and the documentation provided was incomplete and incorrect, violating the facility's policy for controlled substance management.
A resident with Parkinson's Disease, falls, and dementia was prescribed Doxycycline without a documented indication for its use. The facility's records, including nurse's notes and physician's progress notes, failed to identify a reason for the antibiotic use or any chronic skin condition. The resident's quarterly MDS also noted the use of an antibiotic without indication. Interviews revealed a lack of awareness regarding the resident's antibiotic use, and the Dermatology Consultant's Office Manager confirmed the resident had been taking Doxycycline intermittently for Rosacea flare-ups but had not been seen by the provider since 2022.
The facility failed to properly store controlled drugs, label over-the-counter medications with open dates, and monitor medication refrigerator temperatures. Controlled drugs were not stored in a separately locked, permanently affixed compartment, and the key was easily accessible. Over-the-counter medications lacked open dates, and the facility did not maintain temperature logs for the medication refrigerator, which is essential for storing certain medications and vaccines.
The facility failed to ensure proper hand hygiene during medication administration and resident care. An LPN did not perform hand hygiene while administering medications to two residents, and a nurse aide failed to change gloves or wash hands between handling dirty dishes and assisting residents. The DON confirmed these actions were against the facility's handwashing policy.
Failure to Supervise Smoking, Maintain Shower Equipment, and Ensure Wheelchair Footrests
Penalty
Summary
The facility failed to ensure appropriate supervision and monitoring to prevent smoking in the facility, failed to ensure wheelchair leg rests were in place to prevent a fall, and failed to ensure equipment was maintained to prevent a fall from a shower chair. The report includes findings from three sampled residents with accidents and/or smoking-related concerns, along with observations, clinical record review, facility policy review, and staff interviews. Resident #5 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, occlusion and stenosis of the left carotid artery, and anxiety disorder. The quarterly MDS identified the resident as severely cognitively impaired, requiring substantial to maximal assistance with bed mobility and transfers, total assistance for dressing and personal hygiene, and wheelchair use for mobility. The care plan identified fall risk interventions, but the resident fell from a shower chair during a shower and sustained a skin tear to the right elbow. The facility reportable event stated the shower chair collapsed and the resident struck the head and posterior trunk. Staff interviews identified that the resident was calm at the time, the shower chair broke at the seams, and the maintenance department did not complete regular inspections or maintenance on shower chairs. The administrator could not identify the age of the shower chair, and the investigation did not identify a root cause beyond calling it a freak accident. Resident #31 was admitted with asthma, opioid dependence, peripheral vascular disease, and nicotine dependence. The care plan stated the resident had been smoking in the community before admission, was informed the facility was non-smoking, and agreed not to possess smoking materials. Despite this, nursing and social services notes documented incidents of cigarette smoking and possession of a lighter and cigarette butt in the room, including a room search that found a lighter and later confiscation of smoking items. Review of the record and facility documentation from April 2025 through May 2026 did not identify monitoring for prohibited items, follow-up smoking cessation education, or A&I reports for the cigarette incidents. During survey observations, the resident’s room and bathroom smelled strongly of cigarette smoke, and the resident later surrendered cigarettes and a lighter. Staff interviews confirmed awareness of the resident’s smoking when out of the building, but the DNS stated she did not complete an A&I or investigate or report the smoking incidents. Resident #57 had diagnoses including dementia, anxiety, and osteoarthritis of the knee. The quarterly MDS identified severely impaired cognition, dependence on staff for wheelchair mobility, and maximal assistance with transfers, dressing, bed mobility, and personal hygiene. The resident fell in the dining room after sliding from the wheelchair and was found on the floor in front of the wheelchair with no injuries. The fall investigation identified the root cause as lack of footrests on the wheelchair and noted the intervention to prevent future falls was to ensure footrests were in place. Interviews with rehabilitation and nursing staff confirmed the resident did not self-propel, needed the footrests/leg rests in place when seated or transported, and that the footrests were not in place at the time of the fall.
Failure to Timely Notify MD/APRN of Bruising of Unknown Origin
Penalty
Summary
The facility failed to ensure that the MD/APRN was notified in a timely manner when Resident #57 developed bruising of unknown origin on both forearms. Resident #57 had diagnoses including dementia, anxiety, and osteoarthritis of the knee, and the quarterly MDS identified severely impaired cognition, dependence for most ADLs, wheelchair use, and no existing wounds or skin problems. The care plan identified the resident as at risk for skin breakdown related to decreased mobility and incontinence, with interventions including Geri-sleeves, gentle handling during transfers and care, and skin inspection during care. The reportable event form documented that staff observed two bruises/purpura on the right and left forearms and that the resident denied pain and did not know the origin of the bruising. Although the form stated APRN #1 was notified on 4/6/26, the nursing progress note did not document notification, and APRN #1 stated she was not made aware until 4/10/26. Interviews with the ADNS and DNS indicated the MD/APRN should have been notified when the bruising was identified, not 72 hours later. APRN #1 later documented bilateral forearm bruising that had been noted by nursing the prior week and confirmed the areas were bruises.
Failure to Thoroughly Investigate Bruising of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate bruising of unknown origin on a resident with diagnoses including dementia, anxiety, and osteoarthritis of the knee. The quarterly MDS identified the resident had severely impaired cognition, required maximal assistance with personal care and transfers, and was dependent on staff for wheelchair use and toileting hygiene. The care plan identified the resident was at risk for skin breakdown related to decreased mobility and incontinence, with interventions including Geri-sleeves, gentle handling during transfers and care, and skin inspection during care. Staff identified bruising to both forearms, and the reportable event noted the resident denied pain and did not know the origin of the bruises, with no witnesses identified. APRN documentation later noted bilateral forearm bruising that appeared dark red to maroon, and the resident stated that somebody hurt him/her, although the resident could not provide further information due to significant dementia. The DNS and ADNS acknowledged that statements were not obtained when the bruises were first identified, that staff who cared for the resident in the 24 hours before the bruising should have been interviewed, and that the 4/6/26 incident was not thoroughly investigated separately before being treated as a follow-up to the later report.
Incomplete Bruise Assessment and Delayed Surgical Wound Treatment
Penalty
Summary
The facility failed to ensure that bruising of unknown origin on one resident’s bilateral forearms was assessed according to acceptable standards of practice and the facility’s policy. The resident had diagnoses including dementia, anxiety, and osteoarthritis of the knee, and the quarterly MDS identified severely impaired cognition with dependence for multiple activities of daily living. The care plan identified the resident as at risk for skin breakdown and directed staff to use Geri-sleeves, handle the resident gently during transfers and care, and inspect the skin during care for signs of breakdown. When staff reported bruises on the resident’s right and left forearms, the reportable event documentation did not include a description of the bruises such as color, swelling, surrounding skin appearance, location, or measurements. The clinical record also did not contain this information for the date the bruises were first observed. The RN responsible for the assessment acknowledged that a thorough assessment had not been completed when the bruises were found and that the note documenting the bruises was not entered until three days later. He also stated that he had not notified the APRN or physician when the bruising was reported. Facility staff identified that the post-accident/incident monitoring should have started when the bruising was first identified and that the 72-hour monitoring form was intended to track changes in the resident’s condition. The facility also failed to ensure timely treatment for another resident’s surgical wound. This resident was admitted with a displaced bicondylar fracture of the left tibia and required extensive assistance with toileting, personal hygiene, bed mobility, and transfers. After hospitalization for infection of the left lower leg and revision of the left tibia fracture, the discharge summary directed daily wound care to the left lower leg using Xeroform, Kerlix, and an ACE wrap. However, the physician’s orders on readmission did not include an active treatment order for the surgical wound until three days later, and the first documented wound treatment in the TAR occurred after that delay. The admitting nurse stated she missed the wound care instructions in the discharge summary and believed the dressing should remain in place until the follow-up visit, while facility leadership confirmed the discharge instructions should have been transcribed into orders on the day of admission.
Failure to Timely Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to ensure timely notification to the State Agency regarding an allegation of verbal abuse between two residents. On the date of the incident, one resident with a history of bipolar disorder and moderate cognitive impairment engaged in a verbal confrontation with another resident who was alert and oriented. The confrontation included threats of physical violence, with one resident referencing a prior incident where physical aggression had occurred. Staff, including a social worker, observed and documented the altercation, and the involved residents were separated. The resident who initiated the threats was later calmed and escorted back to their room by the ADNS. Despite multiple staff members documenting the incident in the medical record, there was a breakdown in communication regarding the reporting of the event. The social worker, psychiatric APRN, and nursing staff all made notes about the incident, but the DON was not informed about the resident-to-resident verbal aggression and threats. The DON stated that if she had been notified, she would have recognized the event as an allegation of verbal abuse and reported it to the State Agency as required by facility policy. The facility's abuse policy mandates that allegations of abuse be reported promptly, with supervisors immediately notifying the DON and Administrator, who are responsible for reporting to the State Agency within two hours. However, the State Agency was not notified until 51 days after the incident, following inquiry by surveyors. This delay constituted a failure to follow established procedures for timely reporting of suspected abuse.
Failure to Provide Proper PPE Disposal and Monitoring for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper implementation of Enhanced Barrier Precautions (EBP) for nine residents who required personal protective equipment (PPE) due to being on precautions for multidrug-resistant organisms (MDROs). Observations and interviews revealed that trash receptacles for discarding PPE were not positioned inside the doorways of the affected residents' rooms, as required by CDC guidance. Instead, the only available trash cans were located inside the bathrooms with closed doors, making it difficult for staff to properly dispose of contaminated PPE upon exiting the rooms. Staff interviews confirmed that, due to a shortage of trash receptacles, PPE was sometimes discarded in bathroom trash cans or in community hallway trash cans rather than at the point of exit from the resident rooms. Additionally, the infection control nurse, who was responsible for ensuring the availability of precaution supplies and monitoring staff adherence to EBP, had not conducted the required spot checks of the rooms. The facility's EBP policy did not address the required placement of trash receptacles or the need for periodic monitoring of staff compliance. These lapses were identified through review of facility records, direct observation, and staff interviews, and were not corrected until after the deficiency was observed.
Failure to Timely Revise Care Plans After New Skin Impairments Identified
Penalty
Summary
The facility failed to review and revise Resident Care Plans (RCPs) to include additional interventions after the identification of new skin impairments for three residents. For one resident with a history of cellulitis, rheumatoid arthritis, and chronic pain syndrome, a new open area on the right foot was identified and treated, but the RCP was not updated to reflect the presence of rheumatoid arthritis nodules or the new skin impairment until more than a month later, after the resident had passed away. Documentation showed that the resident had multiple wounds, including a large full-thickness wound, but the care plan did not include these findings or new interventions in a timely manner. Another resident with subarachnoid hemorrhage and epilepsy developed pressure ulcers on the right lateral foot and ankle, which remained unhealed for several months. Although nursing notes indicated that the RCP was updated with new interventions, a review of the clinical record did not show any revisions or additional interventions added to the RCP for over a year. The care plan continued to list only general interventions, such as skin inspection and offloading heels, without addressing the new or ongoing wounds. A third resident with dementia, diabetes, peripheral vascular disease, and neuropathy developed a diabetic wound on the right second toe. Nursing documentation noted the wound and indicated that the RCP was updated, but no revisions or new interventions were found in the care plan for nearly a year. Interviews with nursing staff confirmed that RCPs should be revised immediately upon discovery of new skin impairments, but they were unable to explain why this was not done for these residents. Facility policies required timely and interdisciplinary updates to care plans to address changes in resident status, but these were not followed in the cases reviewed.
Failure to Complete Weekly Skin Assessments per Physician Orders
Penalty
Summary
The facility failed to complete weekly skin assessments as ordered by physicians for three residents with significant risk factors for skin breakdown and wounds. For one resident with diagnoses including cellulitis, rheumatoid arthritis, and chronic pain syndrome, a physician's order required weekly body audits on shower days. While one audit was documented, subsequent weekly audits were missing for several weeks. During this period, the resident developed multiple skin impairments, including an open foot ulcer and cellulitis, which were only identified after a significant lapse in weekly assessments. The care plan addressing skin breakdown risk factors was not updated until well after the impairments were identified and after the resident's passing. Another resident with a history of subarachnoid hemorrhage and epilepsy was also subject to a physician's order for weekly body audits. Documentation showed that after an initial audit, no further weekly audits were recorded for several months, despite the resident developing pressure ulcers on the right lateral foot and ankle. Nursing notes and the wound tracker confirmed that these wounds remained unhealed and required ongoing wound care, yet there was a lack of consistent weekly documentation as required by the physician's order and facility policy. A third resident, diagnosed with dementia, diabetes, peripheral vascular disease, and neuropathy, also had a physician's order for weekly body audits. The clinical record revealed no completed weekly audits for an extended period, during which the resident developed a diabetic wound on the right second toe. Nursing documentation of skin assessments was absent until weeks after the wound was identified. Interviews with facility staff confirmed that weekly skin audits were expected per physician orders and facility policy, but these were not consistently performed or documented for the residents in question.
Delayed Removal of Narcotic Medication After Resident Death
Penalty
Summary
The facility failed to ensure the timely removal of a narcotic medication, Dilaudid, from the medication cart following the death of a resident with diagnoses including cellulitis, rheumatoid arthritis, and chronic pain syndrome. The resident had a physician's order for Dilaudid to be administered as needed for severe pain, and the medication was last given prior to the resident's death. Despite the resident being pronounced dead, the Dilaudid remained in the medication cart for 20 days before being removed and returned to the office, as documented in the pharmacy Controlled Substance Disposition Record. Interviews with nursing staff and administrative personnel revealed that the process for removing narcotics after a resident's discharge or death was not consistently followed. Staff reported delays in removing narcotics due to lack of prioritization and refusal by the previous Director of Nursing Services (DNS) to co-sign for removal. The facility's policy directed that discontinued medications should be removed from the resident's supply once an order is received, but this was not adhered to in this case, resulting in the narcotic remaining accessible in the medication cart well beyond the resident's death.
Failure to Conduct Required Elopement Risk Assessments
Penalty
Summary
The facility failed to conduct quarterly elopement risk assessments in accordance with its own policy for one of three sampled residents who left the facility without staff knowledge. The resident, who had diagnoses including hemiparesis following a stroke, depression, and anxiety, was identified as having some memory recall deficits and self-propelled in a wheelchair. The care plan noted depression related to restricted physical activity, but interventions did not address elopement risk. On the day of the incident, the resident was discovered missing during a medication pass, was not signed out, and was later found by police at a nearby gas station. The resident stated this was the first time leaving the facility without a family member. Review of the clinical record showed the last elopement risk assessment was conducted over eight months prior, with the next assessment only completed after the elopement event, at which point the resident was identified as at risk and a wanderguard was initiated. Further review revealed the facility did not consistently conduct elopement assessments quarterly as required by policy, affecting an additional eighteen of fifty-one residents. The facility policy required elopement risk assessments on admission, readmission, quarterly, with a change in condition, and after an elopement attempt, but this was not followed.
Failure to Obtain Advance Directives and Code Status on Admission
Penalty
Summary
The facility failed to review and obtain advance directives and code status for three residents upon their admission. Resident #257 was admitted with diagnoses including alcoholic cirrhosis of the liver, muscle weakness, and difficulty walking. The Medical Interventions Consent form was not completed at the time of admission, and the physician's orders did not specify the resident's code status until five days later. The resident was responsible for themselves, and the delay in completing the necessary documentation was acknowledged by the nursing staff. Resident #258, admitted with osteomyelitis, chronic obstructive pulmonary disease, and a non-ST elevation myocardial infarction, also experienced a delay in the completion of the Medical Interventions Consent form and the physician's order for code status. The form remained blank upon admission, and the resident's choices were not documented until five days later. The nursing staff recognized that the documentation should have been completed on admission. Similarly, Resident #260, with diagnoses including syncope, neoplasm of the brain, and atrioventricular blocks, did not have their Medical Interventions Consent form completed until four days after admission. The resident's code status was not documented in the physician's orders until this time. The facility's policy requires that advance directives be reviewed and documented upon admission, but this was not adhered to for these residents.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that a physician-ordered medication was administered by a licensed nurse and was not left at the bedside for Resident #26. The resident, who had chronic respiratory failure, heart attack, and stroke, was found with a bottle of saline nasal spray at the bedside, which was expired. The nurse assigned to the resident discarded the expired nasal spray and replaced it with a new one, which was then locked in the medication cart. The facility's policy required that medications be kept in a locked location unless the resident was evaluated and deemed capable of self-administration, which had not been done for Resident #26 until after the surveyor's inquiry. The facility also failed to utilize resident identifiers during medication administration for two residents. For Resident #308, the LPN administered medications without verifying the identification band, relying on memory from the previous day. Similarly, for Resident #31, another LPN administered medications without checking an identification band, as the resident was not wearing one. The facility's policy required the use of at least two identifiers before administering medication, which was not followed in these instances. The facility's policies on self-administration of medication and medication administration were not adhered to, leading to these deficiencies. The policies required that medications be stored securely and that residents be evaluated for self-administration capabilities. Additionally, the policies mandated the use of resident identifiers to ensure correct medication administration, which was not consistently practiced by the nursing staff.
Deficiencies in Fall Assessments, Medication Administration, and Catheter Orders
Penalty
Summary
The facility failed to ensure proper neurological assessments and post-fall assessments were completed for two residents who experienced multiple unwitnessed falls. One resident, with a history of Alzheimer's Disease and a recent femur fracture, was found on the floor on two separate occasions without documented neurological checks for 72 hours post-fall, as required by the facility's policy. Another resident, with chronic health conditions and a history of falls, experienced several unwitnessed falls over a period of months. The clinical records for these incidents lacked complete neurological assessments and post-accident and incident monitoring, which should have been conducted every shift for 72 hours following each fall. The facility also failed to administer an anxiolytic medication according to the physician's order for a resident with a history of mental health issues, including anxiety and depression. The resident missed four doses of Alprazolam due to the medication being unavailable, which led to the resident experiencing nausea and vomiting. The pharmacy did not receive the order or a signed prescription until several days after the resident's admission, resulting in the medication being delivered late. This oversight was acknowledged by the facility's DNS, who noted that the physician was unavailable to sign prescriptions during this period. Additionally, the facility did not obtain a physician's order for an indwelling catheter for a resident admitted with a catheter in place. The resident's records indicated the presence of a Foley catheter, but there was no evidence of a physician's order for its use. An RN confirmed that there should have been a diagnosis and an order for the catheter, highlighting a lapse in following proper protocol for medical device management.
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to provide necessary supervision and implement timely interventions to prevent falls for a resident identified as being at high risk for falls. The resident, who had chronic myeloproliferative disease, COPD, and difficulty walking, was admitted with a care plan that included keeping the call bell within reach and ensuring a clutter-free environment. Despite these measures, the resident experienced multiple unwitnessed falls, starting with a fall from bed on February 26, 2024, and continuing with several other incidents, including falls in the bathroom and while seated in a wheelchair. The care plan was not consistently updated with new interventions following each fall, indicating a lack of adequate response to the resident's changing needs. For instance, after a fall on March 8, 2024, the care plan was updated 13 days later to include keeping the resident's shoes within reach. However, subsequent falls on April 8, April 9, May 1, and May 15, 2024, did not result in new interventions being implemented. It was only after a fall on July 5, 2024, that an intervention was added to ensure the resident was not left unattended in the Serenity room. Observations during the survey period revealed that the resident was often left without supervision, particularly in the Serenity room, which was not directly visible from the nurse's station. The facility's policy on falls required that each fall be evaluated and the care plan updated with strategies to prevent future incidents, but this was not consistently followed. The Director of Nursing, who had been employed for eight weeks, acknowledged the frequent falls and was working to improve fall interventions, but the lack of timely and effective measures contributed to the ongoing risk of falls for the resident.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility failed to ensure daily weights were completed for a resident with a physician's order for daily monitoring due to congestive heart failure (CHF). The resident, who had diagnoses including acute chronic systolic heart failure, Alzheimer's Disease, and anorexia, was admitted with a care plan that required daily weight monitoring. Despite the physician's order dated 7/25/24 to weigh the resident daily and report significant weight changes, the facility did not obtain weights on 14 out of 19 days between 7/25/24 and 8/12/24. This resulted in an unmonitored weight loss of 8.5 pounds, representing a 7.07% loss. Interviews with facility staff revealed a lack of awareness and communication regarding the daily weight order. An LPN was unaware of the order and did not receive reports of the resident's weight loss. Another LPN acknowledged the order but did not weigh the resident on nights when the resident was sleeping and failed to notify anyone of the missed weights. The RN Supervisor and DNS both expected weights to be completed as ordered, but the facility's weight monitoring policy was not followed, leading to the deficiency.
Failure to Maintain Accurate Controlled Drug Records
Penalty
Summary
The facility failed to maintain an accurate record of receipt and disposition of controlled drugs brought into the facility from an outside pharmacy. During an observation, it was noted that the Director of Nursing Services (DNS) stored discontinued controlled drugs in a locked file cabinet in her office, which was supposed to be secured by the office door acting as a second lock. However, the office door was found wide open with no staff present, and the key to the file cabinet was easily accessible, hanging visibly from a lanyard in the office. Upon inspection, it was discovered that two controlled drugs, Tramadol and Clonazepam, brought in by residents from an outside pharmacy, lacked proper reconciliation forms. The facility's documentation was insufficient to enable accurate reconciliation of these medications. The Resident Medication Sheet provided for Clonazepam was incomplete and contained incorrect information, such as the wrong strength of the medication. Additionally, a Post-it note attached to the form did not provide adequate details for reconciliation, missing critical information like the medication's name, strength, quantity, and the resident's name. The facility's policy required controlled substances to be counted and documented at each shift change or at least once daily, but no reconciliation forms had been maintained for these medications since April 2024. The facility contacted a former nursing supervisor who admitted the residents with these medications, but the lack of proper documentation persisted.
Inadequate Indication for Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to ensure an adequate indication for the prophylactic use of an antibiotic for a resident with a history of Parkinson's Disease, falls, and dementia. The resident was prescribed 50mg of Doxycycline daily without a documented indication for its use. Both the nurse's notes and physician's progress notes from early March to late March did not identify any reason for the prophylactic antibiotic use or any chronic skin condition. The resident's quarterly MDS also noted the use of an antibiotic without indication and did not identify a skin problem. An APRN note later identified the resident had chronic impetigo, but no episodes occurred while at the facility, and the Doxycycline was prescribed by dermatology. The care plan failed to address the prophylactic antibiotic use or any chronic skin condition. Interviews with the Infection Control Nurse revealed a lack of awareness regarding the resident's antibiotic use and the absence of consultation reports from the dermatologist. The Dermatology Consultant's Office Manager confirmed the resident had been taking Doxycycline intermittently for Rosacea flare-ups but had not been seen by the provider since 2022. The facility's Antibiotic/Antimicrobial Stewardship policy emphasizes treating residents with symptomatic infections only and reviewing antibiotic usage, which was not adhered to in this case.
Deficiencies in Drug Storage and Temperature Monitoring
Penalty
Summary
The facility failed to store controlled drugs in a separately locked, permanently affixed compartment, and did not limit access to these drugs. During an observation, it was found that discontinued controlled drugs were stored in a file cabinet in the Director of Nursing Services' (DNS) office, which was not permanently affixed and had only one lock. The office door, intended to act as a second lock, was left open with no staff present, and the key to the file cabinet was easily accessible. The DNS admitted to not keeping the office door closed and locked and acknowledged that the key should have been carried on her person. Additionally, the facility did not ensure that over-the-counter drugs were labeled with an open date as per facility policy. During a medication administration observation, several pill bottles in the medication cart were found to be opened and lacked open dates. The DNS confirmed that all over-the-counter medications should be dated with an open date and discarded after 30 days, and the date should include a day, month, and year. The facility also failed to monitor and record the temperatures of the medication refrigerator, which is crucial for storing certain medications and vaccines at the correct temperatures. During an observation, it was found that the medication refrigerator temperature log was blank, and the facility was unable to provide temperature logs from March 2024 through July 2024. Interviews with nursing staff revealed that third shift nurses were responsible for monitoring the refrigerator temperatures, but the DNS was unaware of a process for this monitoring.
Failure in Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene practices during medication administration and resident care, as observed in two separate instances involving licensed staff and nurse aides. During a medication administration observation, an LPN did not perform hand hygiene at any point while preparing and administering medications to two residents. The LPN admitted to forgetting to wash her hands during the process. This oversight was noted during a surveyor's observation and was acknowledged by the Director of Nursing, who confirmed that hand hygiene should be performed before and after administering medications. In another instance, a nurse aide was observed failing to perform hand hygiene while collecting dirty dishes from multiple resident rooms and after removing gloves. The nurse aide entered several resident rooms without changing gloves or performing hand hygiene, even after handling dirty dishes and assisting a resident with positioning. The nurse aide admitted to not knowing the proper hand hygiene protocol after glove removal and continued to handle items with dirty gloves. The Director of Nursing confirmed that hand hygiene should be performed before and after entering resident rooms and after removing gloves, as per the facility's handwashing policy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 191 citations issued within 25 miles in the last 12 months — including the 8 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mystic
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mystic Healthcare & Rehabilitation Center, Llc | 0.9 mi | ★★★★★ | 20 | 1 |
| Pendleton Rehabilitation And Nursing Center | 1.4 mi | ★★★★★ | 1 | 0 |
| Avalon Health Care Center At Stoneridge | 1.6 mi | ★★★★★ | 1 | 0 |
| Complete Care At Groton Regency | 4.1 mi | ★★★★★ | 13 | 0 |
| Fairview | 6.2 mi | ★★★★★ | 3 | 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.