Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mystic Healthcare & Rehabilitation Center, Llc during CMS and state inspections, most recent first.
A resident with hemiplegia, muscle weakness, and impaired gait required two-person transfers using an ETAC device per the physician order, care plan, and RCC. An NA instead used a stand-pivot transfer without the ordered equipment, and the wheelchair rolled as the resident was being seated, causing the resident to fall to the floor and sustain a left hip fracture requiring surgical repair. The resident had been cognitively intact and dependent on staff for transfers and wheelchair mobility.
A resident with Alzheimer's Disease, severe cognitive impairment, and known wandering and exit-seeking behaviors eloped through a rear exit door. RN and RA staff found the resident outside and escorted the resident back in without injury, but the DON did not interview all potential staff witnesses from the affected shifts to determine how the resident exited or whether the rear door had been left open, and the investigation was not thorough.
Failure to complete elopement assessments on admission and re-admission. An LPN did not document wandering/elopement assessments for three residents at the time of admission or re-admission, including a resident with Alzheimer’s disease and a known history of elopement who had previously worn a wanderguard. That resident’s assessment was delayed, the wanderguard order was not renewed on return from the hospital, and the resident later exited the facility unattended before staff escorted the resident back inside.
Failure to Implement Elopement Interventions: A resident with severe cognitive impairment, wandering, and exit-seeking behaviors exited through a rear door unattended after existing elopement interventions were not fully implemented. The resident had a history of Alzheimer’s disease and other neurologic and psychiatric diagnoses, was known to need a wanderguard, and staff had discussed a secure dementia unit due to wandering and agitation. After readmission from BH, an LPN failed to complete an elopement assessment and obtain a new wanderguard order, and the resident was later observed outside before being brought back inside by staff.
A facility failed to maintain a safe environment when a dirty meal tray cart with uncovered leftover food and an open garbage was routinely left overnight in a hallway outside a locked kitchen, accessible to cognitively impaired, wandering residents on modified diets, including pureed and mechanical soft textures with thin liquids. One resident with dementia, dysphagia, severe memory deficits, and dependence on staff for eating accessed a peanut butter sandwich from the unattended cart and choked, requiring an LPN to perform the Heimlich maneuver. Staff interviews revealed that this resident habitually wandered at night seeking food and had previously attempted to take food from the cart, but these behaviors were not reported to licensed staff. The Director of Food Service and DON were aware that the cart was not consistently locked in the kitchen, and a new RN supervisor on duty had not been oriented to the meal tray collection and cart storage process. The facility lacked a specific policy on food cart storage or food disposal, despite having general policies on safe environment and management of wandering and elopement risk, resulting in an Immediate Jeopardy finding.
A resident with dementia, COPD, dysphagia, severe memory deficits, and dependence on staff for eating had a care plan and Resident Care Card directing a regular pureed diet with thin liquids, aspiration monitoring during meals, and removal of accessible food due to food-seeking behavior. Staff failed to follow these directives when the resident, who habitually wandered at night looking for food, accessed a peanut butter sandwich from a food cart and choked, requiring an LPN to perform the Heimlich maneuver. A NA had previously seen the resident attempt to take and eat food from the cart, did not report these incidents to nursing staff, was unaware of the prescribed pureed diet, and provided snacks at night without knowledge of dietary restrictions, while the DON was unaware of the prior food cart incidents.
A resident with dementia, dysphagia, severe memory deficits, and dependence on staff for eating was care planned and ordered for a regular, pureed diet with thin liquids and had a Wanderguard for wandering risk. During a night shift, the resident, who habitually wandered the halls seeking food, accessed a food cart outside the locked kitchen, took a peanut butter sandwich inconsistent with the prescribed diet, and began choking. A NA observed the choking and alerted an LPN, who performed the Heimlich maneuver. The NA reported having previously seen the resident attempt to take and eat food from the food cart but did not report these behaviors to licensed staff and was unaware of the resident’s pureed diet, while the DON was unaware of the prior unsafe eating incidents.
Failure to obtain required resident weights. The facility did not complete admission, monthly, or reweight checks for multiple residents with significant medical needs, including dysphagia, dementia, CHF, DM, and ESRD. An LPN, RN, MDS staff, Dietician, and DON/DNS could not explain missing weights in the EMR, and one resident had a documented 19-lb loss while another had a 15.1-lb loss after readmission. Physician orders called for admission and follow-up weights, but the records showed blank admission weight fields and missing monthly documentation.
Opened medications in multiple medication carts and medication rooms were found without open dates or expiration dates. An LPN on one cart and another LPN on a second cart acknowledged that opened meds should be labeled per policy but had not been doing so, and the DON also found unlabeled opened Humalog, acetylcysteine, Tubersol, and azelastine ophthalmic solution in the med rooms.
A resident with a urinary catheter was observed with the drainage bag hanging at the foot of the bed and visible from the hallway without a privacy cover, despite facility policy stating catheter drainage bags should stay covered. In separate interviews, two residents reported staff used undignified language, including calling residents inmates and making dismissive comments about providing care, and one resident reported being ignored by NAs and hearing a nurse make an inmate reference before entering the room.
Failure to notify emergency contact after a resident fall. A resident with sacral fracture, difficulty walking, CHF, and moderate cognitive impairment had an unwitnessed fall, but the resident’s representative was not informed. Staff documentation noted the responsible party had not been notified, while the LPN and DON both stated facility policy required family/emergency contact notification after a fall and that the contact information was available in the record.
Failure to include PTSD interventions in a resident care plan. A resident with diabetes, anxiety, PTSD, and moderate cognitive impairment had a care plan that did not identify PTSD or include interventions for PTSD-related triggers or distress. Psychiatric notes documented PTSD, and staff interviews showed the care plan update was overlooked and that the facility did not have a PTSD policy at the time.
Improper Needle Used for Ordered Subcutaneous Injection: An LPN was observed preparing Octreotide Acetate for a resident with GI inflammation and tube feedings, but used an IM syringe with a 1-inch large-bore needle for an ordered subcutaneous injection. The surveyor intervened before administration, and the LPN acknowledged the error and redrew the medication with the correct 1 mL syringe and 5/8-inch needle. The DNS stated facility policy required specific syringe and needle selection for subcutaneous injections.
Failure to Offer Activities to a Dependent Resident: A resident with anxiety, neuropathy, and suspected adult neglect was identified as valuing reading materials and favorite activities, but was not offered activities on a daily basis. The resident was observed in bed without reading materials and stated staff never offered activities or assistance to attend them, despite being unable to self-propel the wheelchair. Records showed only one 1:1 visit during the month, and the TRD stated the resident was not offered more activities because prior refusals caused activities to "trail off."
Failure to Offload Heels and Follow Wound Orders: A resident with dementia, severe malnutrition, and a pressure ulcer to the left ischium was observed lying in bed without heels offloaded despite a physician order for heel elevation or foam boots. An LPN also failed to follow wound care orders by applying the wrong treatment to the left ischium, initially confusing the ischium with the hip and not applying the ordered Triad to the peri-wound area.
A resident with dementia with behavioral disturbance received Seroquel, but the record did not show routine behavioral monitoring. The care plan identified behavioral disturbance and included monitoring interventions, yet the antipsychotic order was rewritten for dementia after an incorrect schizophrenia diagnosis was removed, and the DON did not reimplement monitoring. Facility policy required behavioral monitoring and documentation of target behaviors and expected outcomes with antipsychotic use.
An LPN failed to follow EBP during PICC line care for a resident receiving IV antibiotics, wearing gloves but not a gown during high-contact device care despite signage requiring both. In a separate observation, an LPN performing wound care for a resident with a pressure ulcer removed gloves and put on a new pair without cleansing her hands after treating another wound and after initially applying the wrong medication.
Failure to initiate QAPI for weight monitoring noncompliance: Staff were not following physician orders or the facility policy for obtaining resident weights, which required weights on admission, weekly x4, then monthly. The DON stated there was no good reason for the noncompliance and that she was responsible for ensuring compliance. The DON and DCS said the Quality Measures for weights had not been triggered, the facility had not identified the problem before the survey team did, and the QAPI for this issue had not been started.
A resident with significant physical and mental health needs was subjected to loud and derogatory remarks by a nursing assistant during toileting care. Two other NAs witnessed the incident and reported that the staff member questioned the resident's need for care and expressed frustration about being assigned to the resident, in violation of facility policies on resident rights and abuse prevention.
A resident with significant care needs was subjected to disparaging and vulgar remarks by a nursing assistant regarding incontinence and food intake. Although two staff members reported the incident to supervisory staff, the nursing supervisor did not escalate the allegation, initiate an incident report, or remove the accused staff member from duty. The DON was not informed until the next day, resulting in a delay in addressing the abuse allegation as required by facility policy.
A resident with cognitive impairment and muscle weakness sustained significant burns to the thigh and genital area after spilling hot chocolate, due to the facility's failure to implement an ordered sippy cup intervention and lack of communication among staff. The resident continued to receive hot beverages in open cups, and required assessments and investigations into the injuries were not completed as per facility policy.
A resident with dementia, muscle weakness, and polyneuropathy developed new wounds that were not promptly addressed in the care plan, with a delay of 10 days before updates were made. Additionally, the care plan did not include interventions for the resident's frequent refusals of care, despite staff being aware of this behavior. Facility policy required timely updates to care plans for changes in resident status, but this was not followed.
A resident with dementia and polyneuropathy experienced injuries of unknown origin, but staff failed to perform a timely full body skin assessment after the initial wound was discovered, and did not document nursing notes every shift as ordered by the physician. Facility policy requiring immediate assessment and documentation of unexplained injuries was not followed, as confirmed by staff interviews and record review.
Several residents with cognitive and physical impairments reported mistreatment and fear related to a staff member, but the facility failed to document grievances, provide required follow-up, or offer timely support as outlined in its own policy. Staff interviews and record reviews confirmed that complaints were not properly recorded or resolved, and administrative staff were unaware of key incidents.
Multiple residents with cognitive and physical impairments reported verbal and physical mistreatment by a staff member, but staff failed to document, investigate, and report these abuse allegations to the State Agency as required by facility policy. Despite some immediate actions, such as staff suspension, there was no evidence of timely notification or proper follow-up.
Multiple residents reported abuse or neglect by a staff member, including physical and verbal mistreatment, but the facility failed to conduct complete investigations or document the allegations as required. Staff did not consistently obtain statements from all involved, and complaints were not always recorded in nurse's notes or the grievance log, resulting in unresolved and uninvestigated incidents.
A resident with dementia and severe cognitive impairment, requiring two staff for care due to behavioral issues, was forcefully pushed into a wheelchair by a staff member who was providing care alone. The resident sustained a bruise and skin tear, and the incident was not promptly reported or investigated according to facility policy, resulting in a failure to protect the resident from abuse.
A resident with dementia and behavioral disturbances, who was care planned for two staff to provide care during a specific shift due to aggression and sundowning, was instead cared for by a single nursing assistant. The staff member was unaware of the updated care plan and the requirement was not communicated, resulting in care being provided alone and an incident involving physical altercation and injury.
Failure to Follow Ordered Transfer Assistance Resulted in Resident Fall and Hip Fracture
Penalty
Summary
A resident with diagnoses including hemiplegia and hemiparesis following a cerebral infarct, abnormal gait, muscle weakness, and bradycardia required assistance of two staff for transfers using an ETAC turn aid with functional design. The physician’s order, care plan, and resident care card all directed two-person assistance with the ETAC device for transfers in and out of bed and chair. The resident was also documented as cognitively intact and dependent on staff for transfers and wheelchair mobility. During a transfer from the wheelchair, an NA used a stand-pivot method instead of the ordered ETAC device and did not follow the resident’s transfer status. The NA stated the wheelchair began to roll as the resident was being seated, and the NA pulled the resident against her body and slid the resident down her leg until the resident landed on the floor on the resident’s bottom. The resident reported left hip pain after the fall and was observed on the floor. The resident’s x-ray showed an acute oblique nondisplaced intertrochanteric fracture of the left hip with diffuse osteopenia, and the resident was sent to the ED for evaluation and treatment. The hospital discharge summary identified surgical repair of the left intertrochanteric hip fracture. The report also states the resident had been fearful and nervous with transfers while therapy was working to return the resident to prior baseline using the ETAC device.
Incomplete Investigation After Resident Elopement
Penalty
Summary
The facility failed to conduct a thorough investigation after Resident #2 eloped through the rear exit door while known to have wandering and exit-seeking behaviors. Resident #2 had diagnoses including Alzheimer's Disease, traumatic subdural hemorrhage, cerebral infarction, depression, and generalized anxiety disorder, and the quarterly MDS identified severe cognitive impairment with a BIMS score of 1. The care plan identified the resident as at risk for wandering and elopement and included interventions such as a picture in the elopement risk binder, walking and exercise, a wanderguard, assistance to find the room, and diversional activities. Following the incident, the DON documented that RN #1 saw Resident #2 in the room shortly before another resident yelled that the resident was outside. RA #1 then saw Resident #2 outside through another resident's window and was the first staff member to reach the resident, with RN #1 approaching from another direction. The resident was escorted back inside without injury, and the physician and family were notified. The DON stated the investigation concluded the resident exited after a staff member used the rear exit door, but staff did not see the resident leave. The DON also stated she did not interview all staff who worked the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shifts to determine who may have entered or exited through the rear door or left it open, and acknowledged the investigation was not thorough. The facility policy required all accidents and incidents to be thoroughly investigated by management.
Failure to complete elopement assessments on admission and re-admission
Penalty
Summary
The facility failed to complete wandering/elopement risk assessments on admission and re-admission for three sampled residents, including a resident with a documented history of wandering and elopement. Resident #2 had diagnoses including Alzheimer's disease, traumatic subdural hemorrhage, cerebral infarction, depression, and generalized anxiety disorder, and was severely cognitively impaired with a BIMS score of 1. The resident care plan identified the resident as at risk for wandering and elopement and included interventions such as keeping the resident's picture in the elopement risk binder, walking with the resident, using a wanderguard on the left ankle, assisting the resident to find the room, and providing diversional activities. However, the nursing admission assessment on 4/7/26 did not show that a wandering or elopement assessment was completed, and the elopement assessment was not conducted until 4/9/26, when the resident was identified as at risk. Resident #2 had previously been identified as an elopement risk and had worn a wanderguard before hospitalization, but upon re-admission the LPN did not complete the elopement assessment or obtain a new wanderguard order. On 4/9/26, the resident exited the facility unattended and was found outside by staff before being escorted back in. For Resident #5 and Resident #6, the nursing admission assessments also failed to document that wandering or elopement assessments were conducted, and the assessments were completed two days after admission for Resident #5 and five days after admission for Resident #6. The DON stated that all residents should have an elopement assessment completed on admission and readmission according to facility policy and the admission checklist, and the facility policy required residents to be assessed for elopement risk and unsafe wandering upon admission.
Failure to Implement Elopement Interventions
Penalty
Summary
The facility failed to implement existing elopement interventions for a resident with severe cognitive impairment and known wandering and exit-seeking behaviors. The resident’s diagnoses included Alzheimer’s disease, traumatic subdural hemorrhage, cerebral infarction, depression, and generalized anxiety disorder. The quarterly MDS identified the resident as severely cognitively impaired with a BIMS score of 1, requiring maximum assistance with oral hygiene, toileting, showers, and bathing, and self-propelling in a wheelchair. The care plan identified the resident as at risk for wandering and elopement and included interventions such as keeping the resident’s picture in the elopement risk binder, walking with the resident to reduce restlessness, using a wanderguard on the left ankle, assisting the resident to find the room, and providing diversional activities. After readmission from the behavioral health hospital, the resident was noted to be interacting appropriately and adjusting well. At the readmission IDT meeting, the team discussed increasing the resident’s walking with staff to help expend energy and a long-term plan to transfer the resident to a secure dementia unit because of wandering and agitation. A psychotherapy note later documented increased anxiety, agitation, confusion, and anger, and stated the resident had been observed outside by another resident and brought back inside. The provider met with the DON and administrator and expressed concern that a locked memory care unit would be more appropriate, and the facility was seeking a bed for the resident. The wanderguard was placed on the resident’s ankle. The incident occurred when RN #1 saw the resident seated in the room, and shortly afterward another resident yelled that the resident was outside. RA #1 observed the resident outside through another resident’s window and reached the resident first, while RN #1 approached from another direction. Staff escorted the resident back inside, and no injuries were observed or reported. The DON’s investigation found that the resident exited through the rear door after a staff member used it and before it re-locked. The resident’s wheelchair was found by the rear exit door. The DON also identified that after readmission, LPN #1 failed to complete an elopement assessment and obtain a new wanderguard order. Interviews with NAs showed that staff were aware of the resident’s elopement risk and had previously redirected the resident from following staff out of the building, but on the day of the incident the resident was able to leave the unit and exit the building unattended.
Immediate Jeopardy from Unsecured Food Cart Access by Wandering Residents with Dysphagia
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment free from accident hazards and to provide adequate supervision to prevent accidents, specifically related to the storage and handling of food carts and leftover food. A food cart used for collecting dirty meal trays was routinely left overnight in the hallway outside a locked kitchen door, without a cover on the cart or on the attached garbage container. This cart, sometimes containing leftover food on plates or in an open garbage, was accessible to cognitively impaired residents with wandering behaviors and prescribed modified diets. The facility did not have a policy addressing food cart storage or proper disposal of food, and the process for securing the cart inside the kitchen was not consistently followed, despite the expectation that the supervising nurse would lock the cart in the kitchen. Four residents with cognitive impairment, dysphagia, and/or wandering and elopement risk were identified as being affected by this unsafe practice. One resident had dementia, COPD, dysphagia, severe memory deficits, was dependent on staff for eating, and was on a regular pureed diet with thin liquids. This resident’s care plan and physician orders included a Wanderguard for wandering and elopement risk and interventions for wandering and nutrition, including a pureed diet and cues to eat slowly. Another resident had cerebral infarction, COPD, diabetes, severe memory deficits, and was on a low concentrated sweet, mechanical soft diet with thin liquids, with a Wanderguard and interventions for wandering and elopement. A third resident had dementia, diabetes, dysphagia, severe memory deficits, required set-up assistance for meals, and was on a low concentrated sweet, no added salt, mechanical soft diet with thin liquids, with a Wanderguard and interventions for wandering. A fourth resident had schizophrenia, anxiety, dysphagia, moderate memory deficits, was independent with eating and mobility, and was on a regular mechanical soft diet with thin liquids, with a Wanderguard and identified risk for choking due to poor dental hygiene. The unsafe environment directly resulted in a choking episode for one resident. During an overnight shift, a nurse aide observed this resident, known to wander the halls at night looking for food and able to open unit double doors, at the food cart outside the locked kitchen door, choking after taking a piece of a peanut butter sandwich from the unattended cart. The LPN on duty performed the Heimlich maneuver, and the resident expelled the sandwich contents and returned to baseline. The nurse aide reported that the resident had previously attempted to take food from the dirty food cart on multiple occasions and had once taken a bite of a sandwich from the cart, but these incidents were not reported to licensed staff. The DON was aware the resident wandered and wore a Wanderguard but was not aware the resident was seeking food from the cart. The Director of Food Service and DON both acknowledged that the cart was not consistently locked in the kitchen, and the new RN supervisor on duty the night of the choking episode had not been trained on the meal tray collection process or the requirement to secure the cart, contributing to the failure to prevent access to the food cart and resulting in Immediate Jeopardy. Additional information from interviews further supports the pattern of unsafe practice. The Director of Food Service described the standard process of using the cart to collect trays, scrape food into the attached garbage, and return the cart to the kitchen, and stated that when dietary staff left at night, an empty cart was left outside the locked kitchen for staff to return remaining dishes, with the expectation that food would be scraped into the open garbage. He reported having previously informed Administration that the cart was not being stored inside the locked kitchen. A dietary aide on the morning shift confirmed that his first task was to empty plates from the cart left in the hallway overnight and that sometimes food remained on plates and sometimes it had been scraped into the open garbage. The Building Specific Orientation Tour for the RN supervisor did not include training on meal tray collection or food cart storage. The facility’s existing policies on providing a safe and homelike environment and on elopements and wandering residents required a safe physical layout and systematic monitoring and management of residents at risk for wandering and elopement, but there was no specific policy addressing food cart storage or food disposal, and the failure to secure the cart and to communicate and act on known wandering and food-seeking behaviors led to the identified deficiency and Immediate Jeopardy.
Failure to Follow Care Plan for Pureed Diet and Aspiration Precautions
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed a resident’s person-centered care plan and Resident Care Card (RCC) regarding a prescribed pureed diet and required monitoring for aspiration. The resident had dementia, COPD, dysphagia, severe short- and long-term memory deficits (BIMS score of 2), was dependent on staff for eating, and was identified as at risk for weight loss, wandering, and elopement. The care plan and RCC directed a regular, pureed texture diet with thin liquids, cues to eat slowly, maintaining an upright position after meals, offering snacks between meals and at bedtime as appropriate, monitoring during meals for aspiration, and removing food from the whole room due to the resident’s tendency to seek food from the roommate. Physician’s orders also specified a regular, pureed texture diet with thin liquids. Despite these directives, staff actions and inactions led to the resident accessing and consuming food inconsistent with the prescribed diet. During the night shift, the resident habitually wandered the hallway looking for food and had previously attempted to take food from the dirty food cart and had taken a bite of a sandwich from the cart, but the NA who observed these behaviors did not report them to a nurse, believing staff were already aware. The NA was not aware the resident was on a pureed diet and reported giving the resident snacks such as chocolate pudding during the night. On one occasion, the resident took a piece of a peanut butter sandwich from the food cart located outside the locked kitchen door and choked on it, requiring the LPN to perform the Heimlich maneuver to expel the sandwich. The DON later stated she was unaware of the prior incidents with the food cart and that the NA should have reported them, while facility policy directed that staff follow the plan of care and Care Card.
Failure to Ensure Staff Awareness of Prescribed Diet and Reporting of Unsafe Eating Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to ensure nursing staff were aware of a cognitively impaired resident’s prescribed pureed diet and to report and address unsafe eating behaviors. The resident had dementia, COPD, dysphagia, severe memory deficits (BIMS score of 2), was dependent on staff for eating, and had care plan interventions for a regular, pureed diet with thin liquids, cues to eat slowly, remaining upright after meals, and snacks between meals and at bedtime. The resident was also care planned and ordered for a Wanderguard due to wandering and elopement risk. Despite these orders and care plan interventions, the resident was able to access a food cart located outside the locked kitchen door and obtain a peanut butter sandwich that was inconsistent with the prescribed pureed diet. On the night of the incident, the resident wandered in the hallway and took a piece of a peanut butter sandwich from the food cart, then began choking. NA #1 observed the resident at the food cart choking and alerted LPN #1, who performed the Heimlich maneuver and the resident expelled the sandwich contents. NA #1 reported that the resident habitually wandered the hallway during the night looking for food, had previously attempted to take food from the dirty food cart, and had been seen taking a bite of a sandwich from the cart, but these prior incidents were not reported to licensed staff because NA #1 believed staff were already aware. NA #1 was not aware the resident was on a pureed diet and had been giving the resident snacks such as chocolate pudding at night. The DON stated she was unaware of the prior sandwich incident and confirmed that NA #1 had not reported the resident’s attempts to take or eat food from the food cart and that such incidents should have been reported to a licensed nurse.
Failure to obtain required resident weights
Penalty
Summary
The facility failed to obtain admission weights, monthly weights, and required re-weights for residents reviewed for nutrition. For Resident #3, who had type 2 diabetes, malignant neoplasm of the lower stomach, atrial fibrillation, and moderate cognitive impairment, the care plan identified dysphagia and a cardiac diagnosis, and a physician order directed monthly weights. However, the record did not contain a November 2025 weight, and the LPN who had obtained weights in other months could not explain why the resident was not weighed that month. The DNS stated the resident should have been weighed in November and that the facility had "dropped the ball." Resident #11 had sepsis, dysphagia, and dementia, and the hospital discharge summary documented a weight of 68.9 kilograms. The nursing admission assessment left the admission weight blank, and the physician ordered an admission weight followed by weekly weights for 4 weeks. The EMR did not show an admission or subsequent weight, although the MDS coded a weight of 152 pounds based on the hospital weight. Staff including the MDS Coordinator, RN supervisor, Dietician, and DNS could not explain why the facility failed to obtain or document the admission weight. After surveyor inquiry, a weight was obtained and documented as 133 pounds, reflecting a 19-pound loss from the hospital weight. The DNS and Director of Clinical Services stated that the weight should have been confirmed with a reweight per policy and that the weight loss was concerning. Resident #78 had chronic combined systolic and diastolic heart failure, diabetes mellitus, and end stage renal disease. The quarterly MDS listed a weight of 201 pounds, and the care plan identified compromised nutritional status with a daily fluid restriction and weights per physician order. On readmission from the hospital, the nursing admission assessment did not document a weight, even though a physician ordered an admission weight and weekly weights for 4 weeks. The facility used a weight obtained at a hemolytic treatment center as the readmission weight, and the record showed a 15.1-pound, 7.26% weight loss in 1 month. Nursing notes did not document an admission weight or the significant weight loss, and the DNS stated that obtaining weights was a team effort but acknowledged there should have been a readmission weight.
Opened medications were left unlabeled in medication carts and rooms
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with accepted professional principles because multiple opened medications in medication carts and medication rooms had no open date or expiration date. During observation and interview with an LPN on the D-wing medication cart, numerous opened items were found without open dates, including CoQ10, docusate sodium, biotin, acidophilus probiotic, multiple strengths of melatonin, Geri-Knot, bisacodyl, probiotic, naproxen sodium, fish oil, calcium, eye relief ophthalmic solution, latanoprost ophthalmic solution, albuterol sulfate inhalation aerosol, fluticasone propionate nasal spray, fluticasone propionate HFA inhalation, and Bevespi Aerosphere. The LPN stated that open medications should be labeled with open and expiration dates per facility policy and acknowledged that he had not been labeling medications as he opened them due to time constraints. On the C-wing medication cart, additional opened medications were observed without open dates, including melatonin 3 mg, melatonin 1 mg, calcium 500 mg, Geri-Knot, and Delsym. The LPN stated that labeling open medications with open and expiration dates was required and that the nurse who opens the medication is responsible for doing so, but also stated she had not checked the cart at the start of her shift as she normally did. In the A/B and C/D medication rooms, the DON observed opened Humalog vial, acetylcysteine solution 20%, two open Tubersol vials, and azelastine hydrochloride ophthalmic solution 5% without open or expiration dates. The DON stated that insulin and eye drops should have expiration dates 28 days after opening and confirmed that the facility policy required opened medications to be dated and assigned an expiration date.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
Resident #2 had diagnoses including flaccid neuropathic bladder, retention of urine, and hematuria, and the quarterly MDS identified moderate cognitive impairment with dependence on staff for toileting and transfers. The care plan addressed altered urinary elimination related to a urinary catheter, and a physician’s order directed catheter insertion. During hallway observations, the resident was seen in bed by the door with the urinary collection bag hanging at the foot of the bed and visible from the hallway, with yellow urine in the bag and no privacy cover in place. Staff interviews confirmed the bag remained in view. A NA stated the bag was hung on the bedside and emptied during the shift, but did not identify a need for a privacy cover or for the bag to be out of view. An LPN stated the bag was kept on the side of the bed as observed and did not identify that it should have been covered or hidden for privacy. An RN also observed the bag in view and did not identify facility policy on urinary collection bags. The DON stated the policy directed urinary drainage bags to hang to gravity and stay covered, and the clinical regional nurse stated there were no privacy bags available in the facility at that time. Resident #9, who had intact cognition on the quarterly MDS, reported hearing staff on the 3:00 PM to 11:00 PM shift refer to residents as inmates and hearing NAs complain about providing care and say they were not babysitters. Resident #9 also stated concerns had not been brought forward previously because staff had told the resident he/she was overstepping when concerns were raised in the past. Resident #73, who had moderate cognitive impairment on the quarterly MDS, reported that NAs turned away and ignored him/her when spoken to and that a nurse had been heard in the hallway saying she had to get the inmate his/her medication before coming into the resident’s room. Resident #73 became tearful while recalling the incident, and the DON stated that referring to residents as inmates would be undignified.
Failure to Notify Emergency Contact After Resident Fall
Penalty
Summary
The facility failed to notify a resident representative/emergency contact after Resident #56 had an unwitnessed fall. Resident #56 had diagnoses including fracture of the sacrum, difficulty walking, and diastolic congestive heart failure, and the care plan identified the resident as a fall risk related to left hip pain with interventions including appropriate footwear, lowest bed position, and frequent rounding for safety and redirection. A reportable event form documented the unwitnessed fall, and the post-fall evaluation noted that the responsible party had not been notified because no next of kin was listed at the time due to the resident being newly admitted. The admission MDS identified Resident #56 as moderately cognitively impaired and needing assistance with eating and transfers. During interview, the resident’s emergency contact stated they were not informed of the fall and learned of it only after requesting and reviewing the medical records. The LPN stated the facility policy required notification of a resident representative/emergency contact after a fall and that the unit nurse or supervisor was responsible for ensuring notification, while the DON stated it was facility policy to notify a family member of a fall and that the nursing supervisor was responsible for ensuring it was completed and documented. Review of the hospital demographics form showed emergency contact information was present in the clinical record at the time of the fall, and the facility’s Fall Prevention program policy directed that when any resident experiences a fall, the family will be notified.
Failure to Include PTSD Interventions in Care Plan
Penalty
Summary
The facility failed to revise Resident #3’s Resident Care Plan to include interventions for triggers related to a diagnosis of PTSD. Resident #3’s diagnoses included diabetes, anxiety, and PTSD, and the Minimum Data Set assessment identified moderate cognitive impairment with a Brief Interview of Mental Status score of 10, along with a need for assistance with bathing and transfers. Review of the Resident Care Plan dated 7/3/25 through 1/14/26 did not identify PTSD or interventions addressing PTSD-related triggers or how to assist the resident when expressions or indications of distress occurred due to PTSD trauma. Psychiatric provider notes from 7/8/25 through 1/7/26 identified PTSD, but the care plan was not updated to reflect that diagnosis. During interviews, RN #3 stated social services should have ensured the PTSD care plan was included in the clinical record, but that responsibility for care planning was building specific, and the facility did not currently have a PTSD policy. LPN #3, the MDS Coordinator, stated she was responsible for updating the care plan and believed she had overlooked implementing a PTSD care plan for Resident #3. The Administrator stated the facility process was to print the PASRR Level II, upload it into the clinical record, and create a care plan for PTSD.
Improper Needle Used for Ordered Subcutaneous Injection
Penalty
Summary
The facility failed to ensure a physician order for Octreotide Acetate injection was administered properly for Resident #41. Resident #41 had diagnoses of gastroenteritis and colitis, was cognitively intact with a BIMS score of 15, and required maximal assistance with eating, bathing, and personal hygiene. The care plan noted the resident was on tube feedings 14 hours per day and received medication through a gastrostomy tube. A physician order in effect directed Octreotide Acetate Injection Solution 100 mcg/ml to be given subcutaneously twice daily for diarrhea. During observation, an LPN was seen drawing up the Octreotide Acetate injection using an intramuscular syringe with a 1-inch, large-bore needle. Before reaching the resident’s room, the surveyor intervened and asked to speak with the LPN outside the room. The LPN reviewed the order and acknowledged the medication had been drawn up with the incorrect needle type. The LPN discarded the syringe and redrew the medication using the correct 1 mL syringe with a 5/8-inch smaller-bore needle for a subcutaneous injection. The DNS stated that, per facility policy, a subcutaneous injection should not be given with an intramuscular-size needle, and the policy included specific instructions for dosage, syringe type, needle size, infection control, and injection site selection and care.
Failure to Offer Activities to a Dependent Resident
Penalty
Summary
The facility failed to ensure activities were offered to a dependent resident with diagnoses including suspected adult neglect, anxiety, and neuropathy. Resident #73’s admission preferences and MDS identified that books, newspapers, magazines, keeping up with the news, and favorite activities were important to the resident. The care plan directed staff to provide activities of interest, including 1:1 visits, assessment of needs and interests, encouragement to participate, assistance with care to be ready for activities, transportation to activities, and materials for individual bedside activities as needed. Observation and interview showed Resident #73 in bed watching television, without reading materials in the room, and with an activity calendar posted on the wall. The resident stated staff never offered activities, had been in bed all day, would have liked to attend activities, and could not get to them independently because the wheelchair could not be self-propelled. Additional observations found the resident alone in bed with the television off and no reading materials. Review of participation records showed only one 1:1 visit in January 2026 and no other activities offered that month. The Therapeutic Recreation Director stated the Recreation Department was responsible for inviting residents to activities, that Resident #73 was not offered activities on a daily basis, and that the resident was not offered more activities because refusals caused activities to "trail off." The director also stated she was unaware the resident wanted more activities or could not self-transport, and the Activities policy required ongoing programs and staff assistance to and from activities when necessary.
Failure to Offload Heels and Follow Ordered Wound Treatment
Penalty
Summary
Resident #98, who had diagnoses including severe protein-calorie malnutrition, dementia, and a pressure ulcer to the left ischium, was identified on admission as alert and oriented to person but chronically disoriented and confused. The care plan identified the resident as at risk for alteration in skin integrity and included interventions to use pressure redistribution devices as ordered and perform treatments as ordered. A physician’s order dated 1/5/26 directed staff to elevate both heels off the bed with pillows or use foam boots to prevent heel ulcers, but observations on 1/7/26 and 1/8/26 found the resident lying in bed without the heels offloaded. The care plan was revised on 1/9/26 to include an increased risk for alteration in skin integrity, and by 1/12/26 the heels were observed to be offloaded. A physician’s order dated 1/9/26 directed wound care for the left ischium to cleanse with wound cleanser, apply Triad to the peri-wound, apply Santyl to the base, secure with a dry clean dressing, and change daily and as needed. The same date, another order directed wound care for the left lower leg using wound cleanser and silver hydrogel with a dry clean dressing. During observation and interview on 1/12/26, an LPN applied silver hydrogel to the left ischium instead of Santyl and initially treated the left lower leg wound as if it were the ischium. After surveyor inquiry, the LPN removed the previously applied ischium dressing and then performed wound care using Santyl, but did not apply Triad to the peri-wound area during either observed ischium treatment. The LPN stated she believed the ischium was the resident’s hip and not the area being treated. The wound RN identified the left ischium as the left lower buttock and stated the LPN had been instructed to seek clarification if unsure of any order.
Failure to Document Behavioral Monitoring With Antipsychotic Use
Penalty
Summary
The facility failed to ensure that behavior monitoring was performed with the administration of Seroquel for Resident #74, who had diagnoses including dementia with behavioral disturbance, substance abuse, and diabetes. The resident’s MDS assessment identified a BIMS score of 12, indicating moderate cognitive impairment, and the resident required assistance with bed mobility and transfers. The care plan in effect from January 2025 through January 14, 2026 identified a behavioral disturbance and included interventions to conduct behavioral monitoring. A physician order dated 1/18/25 directed Seroquel 50 mg at bedtime for schizophrenia, and that order was discontinued on 2/26/25. The antipsychotic medication order was then rewritten for dementia with behavioral disturbance. Review of the clinical record from January 2025 through January 14, 2026 failed to show that behavioral monitoring had been routinely conducted. The Corporate Nurse stated that the previous DON had mistakenly added schizophrenia as a diagnosis and discontinued behavioral monitoring in January 2025, and when the diagnosis was corrected, behavioral monitoring was not reimplemented. The Corporate Nurse also stated that the facility policy required behavioral monitoring with the use of Seroquel for dementia and that antipsychotic medications prescribed for behavioral symptoms should include documentation of target behaviors and expected outcomes.
Failure to Follow EBP and Hand Hygiene During PICC and Wound Care
Penalty
Summary
The facility failed to follow enhanced barrier precautions for a resident with sepsis, dysphagia, dementia, and a PICC line receiving IV ertapenem for sepsis. The resident’s care plan and physician orders identified enhanced barrier precautions related to the PICC line and IV antibiotics, and the doorway sign directed staff to wear gowns and gloves for high-contact care activities involving device care. During observation, an LPN was seen flushing and accessing the resident’s PICC line while wearing gloves but not a gown, despite the sign indicating that gowns and gloves were required for this type of care. When the LPN realized a gown was needed, she stated she had to wear one, then returned to the room and completed the PICC line care without first putting on a gown. The facility also failed to follow hand hygiene practices during wound care for a resident with severe protein-calorie malnutrition, dementia, and a pressure ulcer to the left ischium. The resident had an order for daily wound care using wound cleanser, Triad to the peri-wound, Santyl to the wound base, and a dry clean dressing. During observation of wound care, an LPN initially applied the incorrect medication to the left ischium wound. After treating another wound on the left lower extremity and before re-treating the left ischium with the correct medication, the LPN removed her gloves and put on a new pair without cleansing her hands. The wound RN stated the LPN should have cleansed her hands before donning clean gloves and identified the action as unacceptable.
Failure to Initiate QAPI for Weight Monitoring Noncompliance
Penalty
Summary
The facility failed to initiate a QAPI after identifying that staff had not been following physician orders or the facility policy for obtaining resident weights. The policy for admission weights directed that weights be obtained upon admission, then weekly for 4 weeks, then monthly. The Director of Nursing stated there was no good reason for failing to follow the policy or physician orders, and that although the team met to discuss weights, it was her responsibility to ensure compliance. During interviews, the Director of Nursing and the Director of Clinical Services stated that the Quality Measures for weights had not been triggered and that the facility had not identified the problem with obtaining accurate weights before the survey team identified it. The Director of Clinical Services said the facility runs core reports and sends them to regional staff for review, but the QAPI for this issue had not been started. The Administrator stated the facility uses different sources of information and root cause analysis to decide what Performance Improvement Plans to work on, and the QAPI policy directed monitoring of QI/QM results, internal monitors for falls, medication errors, pressure ulcers, incident reports, and infection reports, with the Quality-of-Care Team meeting monthly.
Failure to Protect Resident from Verbal Mistreatment by Staff
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, hemiplegia, anxiety, and major depression, who was dependent on staff for toileting and other activities of daily living, was subjected to verbal mistreatment by a nursing assistant (NA). The resident was frequently incontinent and required emotional support as part of their care plan. On the evening in question, two other nursing assistants witnessed and reported that the NA assigned to the resident spoke to them in a loud and derogatory manner, questioning why the resident needed to defecate and expressing frustration about having the resident on her assignment. The incident was reported to supervisory staff, and it was noted that the resident appeared stunned by the interaction. Facility documentation and interviews confirmed that the NA's communication style was inconsistent with facility expectations and policies regarding resident rights and abuse prevention. Although the facility's internal investigation did not substantiate abuse due to the resident's inability to recall the incident, multiple staff members corroborated the inappropriate language and tone used by the NA. The supervisor and DON were aware of previous concerns regarding the NA's communication style, but the incident was not immediately investigated in detail at the time it was reported.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
Staff failed to promptly report an allegation of verbal abuse involving a resident who was dependent for toileting, transfers, and bed mobility, and had a history of stroke, anxiety, and major depression. The incident occurred when a nursing assistant (NA) made disparaging and vulgar remarks to the resident regarding their incontinence and dietary intake. Two other staff members witnessed or overheard the incident and reported it to the charge nurse and supervisor. Despite being informed of the incident, the nursing supervisor did not initiate an incident report, notify the Director of Nursing (DON), or remove the accused staff member from duty to protect residents. The supervisor also did not gather specific details about the interaction or recognize the need for immediate escalation, even though she acknowledged that such behavior would be considered abusive. The DON was not notified of the allegation until the following day, resulting in a delay in the investigation and appropriate response. Facility policy required immediate reporting of suspected abuse to management, but this protocol was not followed, leading to a failure in timely reporting and response to the abuse allegation.
Failure to Prevent and Respond to Resident Burns from Hot Beverage Spill
Penalty
Summary
A resident with dementia, generalized muscle weakness, and polyneuropathy experienced multiple incidents resulting in injuries, including burns from a hot beverage spill. The resident was assessed as having moderately impaired cognition and was independent with eating and mobility. Despite this, the resident sustained a significant burn wound to the right inner thigh and genital area after spilling hot chocolate, as identified by occupational therapy and wound care staff. The clinical record did not initially identify the cause of the inner thigh wound, nor did it document wound treatment, monitoring, or preventative interventions after the wound was discovered. Following the burn incident, a physician's order was entered for the resident to use a sippy cup for all beverages to prevent further accidents. However, this intervention was not implemented effectively. Multiple staff members, including nursing assistants, therapy, and dietary staff, were unaware of the sippy cup order, and the intervention was not reflected on the resident's care card or adaptive equipment lists. Observations confirmed that the resident continued to receive hot beverages in open cups, and staff interviews revealed a lack of communication and process for ensuring adaptive equipment orders were followed. Additionally, the facility failed to conduct a full investigation into the injuries of unknown origin, as required by policy. There was no documentation of a completed accident and investigation report for the initial wound, and a full body skin assessment was not performed after the incident. The facility's policy required immediate assessment and investigation of unexplained injuries, but these steps were not documented or completed. The serving temperatures of hot beverages were also found to be high, with no policy provided regarding safe serving temperatures.
Failure to Timely Update Care Plan After New Wounds and Address Refusals of Care
Penalty
Summary
The facility failed to timely review and revise the care plan for a resident following the discovery of new wounds and did not address the resident's frequent refusals of care. Specifically, after a 16 cm by 7 cm skin tear was identified on the resident's right inner thigh, there was no documentation of an intervention being implemented immediately after the wound was discovered. Additionally, the resident's care plan was not updated to reflect the new wound until 10 days after the initial identification. The facility's own policy and the Director of Nursing Services (DNS) confirmed that interventions and care plan updates should have occurred within 24 hours of the incident, but this did not happen. Furthermore, documentation related to the investigation of the injury of unknown origin could not be located by the DNS. The resident, who had diagnoses including dementia, generalized muscle weakness, and polyneuropathy, also had a documented history of refusing care such as bathroom assistance, use of the call bell, personal care, and showering. Despite this, the care plan and care card did not include interventions or strategies to address these refusals, such as reapproaching the resident. Multiple nursing assistants and the DNS confirmed the resident's pattern of refusals, but the social worker responsible for updating behavior-related care plans was not aware of these refusals. The facility's policy required ongoing changes in resident status to be updated in the care plan, but this was not followed in this case.
Failure to Perform Timely Full Body Skin Assessment and Required Documentation After Injury
Penalty
Summary
The facility failed to ensure that a full body skin assessment was performed after the discovery of an injury of unknown origin for a resident with dementia, generalized muscle weakness, and polyneuropathy. After a significant skin tear was identified on the resident's right inner thigh, neither the charge nurse nor the wound nurse completed a full body skin assessment at the time of discovery. The first documented full body skin assessment occurred three days later, which did not reveal any new wounds. Interviews with nursing staff confirmed that the assessment was not performed immediately, as each nurse believed the other would complete it. Additionally, the facility did not comply with physician orders to document nursing notes every shift for 72 hours following the discovery of a wound to the resident's genitals. Review of the clinical record showed multiple shifts where required documentation was missing. The Director of Nursing Services (DNS) confirmed that notes should have been documented every shift per the physician's order, but this was not done. Facility policy required immediate assessment and documentation of unexplained injuries, as well as weekly and as-needed full body skin audits by licensed nurses. Despite these policies, the required assessments and documentation were not completed as directed after the discovery of the resident's injuries. The failure to follow these protocols was confirmed through staff interviews and review of facility documentation.
Failure to Address and Document Resident Grievances and Allegations of Abuse
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without discrimination or reprisal, and did not follow its own grievance policy regarding prompt resolution and support after allegations of abuse or mistreatment. Multiple residents with varying degrees of cognitive and physical impairment reported incidents involving a nursing assistant who was described as rude, rough, and frightening. These residents expressed fear, anxiety, and reluctance to seek assistance due to the staff member's behavior. Despite these reports, there was no evidence in the grievance book or social service documentation that grievances were filed or that the required follow-up and support were provided to the residents. Interviews with staff revealed that although some staff members were made aware of the residents' complaints and concerns, they either did not document the incidents or failed to ensure that grievance forms were completed and submitted according to facility policy. Social service notes did not reflect any follow-up or support for the residents after the allegations, and the required daily meetings with residents for 72 hours following an abuse allegation were not documented. Additionally, administrative staff and the Director of Nursing were unaware of some of the reported incidents and could not locate any related grievance forms or investigations, despite being listed as participants in disciplinary records. The facility's own policy required that concerns and complaints be actively addressed, documented, and communicated to the resident or their representative. However, the review of records and interviews confirmed that these procedures were not followed for several residents who reported mistreatment. The lack of documentation and follow-up resulted in unresolved grievances and a failure to provide the necessary support to residents after allegations of abuse or mistreatment.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure timely reporting of allegations of abuse and mistreatment to the State Agency for four out of six residents reviewed. Multiple residents with varying degrees of cognitive impairment and physical dependency reported incidents involving a nursing assistant who was described as rude, rough, and verbally abusive. These allegations were communicated to various staff members, including occupational therapy, social work, and nursing supervisors. In several cases, residents expressed fear and distress related to the staff member's behavior, and some reported being afraid to request assistance due to concerns about being yelled at or mistreated. Despite these reports, there was a lack of documentation and follow-up regarding the allegations. Staff interviews revealed that while some immediate actions, such as suspending the accused staff member, were taken, there was confusion and inconsistency about whether the incidents met the criteria for abuse and should be reported to the State Agency. Statements and grievances were not consistently documented, and there was no evidence that the required notifications to the State Agency were made. The facility's own policy required immediate reporting of any abuse allegations, but this protocol was not followed. The review of the State Agency Reportable Events website confirmed that none of the incidents involving the four residents were reported as required. Interviews with current and former staff, including the DON and Administrator, indicated an inability to identify or locate documentation related to the incidents. The lack of timely reporting and investigation of these abuse allegations constitutes a deficiency in the facility's compliance with mandated abuse reporting requirements.
Failure to Investigate and Document Abuse Allegations
Penalty
Summary
The facility failed to appropriately investigate and document allegations of abuse or neglect for multiple residents. In one case, a resident with dementia and behavioral disturbances reported being physically assaulted by a staff member, resulting in visible bruising. Although an initial investigation was started, the facility did not obtain statements from all staff present during the incident, as acknowledged by the Director of Nursing Services (DNS) and Administrator. The investigation was therefore incomplete, and not all relevant staff were interviewed. Several other residents with varying cognitive and physical impairments reported concerns about a specific nursing assistant's (NA) behavior, including verbal abuse, rough care, and fear of retaliation. These complaints were reported to various staff members, including nursing supervisors and social workers, but were not consistently documented in nurse's notes or the grievance book. In some cases, staff members who received the complaints did not recall being notified, and there was a lack of follow-up or resolution communicated to the residents. Additionally, statements and documentation related to these allegations were either not completed or not retained, and the facility was unable to identify or locate records of certain complaints and investigations. The facility's abuse prevention policy requires prompt and thorough investigation of all abuse allegations, including interviewing all relevant staff and reporting to the appropriate authorities. However, the report shows that the facility did not follow these procedures for multiple allegations, resulting in incomplete investigations and a lack of documentation. The DNS and Administrator were unaware of some complaints and could not account for missing records or unresolved grievances, indicating systemic failures in responding to and investigating abuse allegations as required by policy.
Failure to Protect Resident from Abuse and Follow Care Plan
Penalty
Summary
A resident with dementia and severe cognitive impairment, who required supervision and two staff for care during certain shifts due to aggression and sundowning behaviors, was involved in an incident where a staff member was observed pushing the resident forcefully into a wheelchair. The resident had a history of combative behaviors and was care planned for specific interventions, including staff explanations and the presence of two staff during care. Despite these interventions, the staff member provided care alone and did not follow the care plan requirements. On the evening of the incident, another staff member witnessed the resident being pushed down into the wheelchair by the shoulders in a manner described as not gentle but a hard push. The resident repeatedly asked the staff member to leave, but the staff member remained, leading to the resident striking the staff member. The resident was later found with a bruise and skin tear on the right hand, which the resident attributed to being punched by the staff member. The incident was not immediately reported to supervisory staff, and initial reports to the nurse on duty were not acted upon or escalated as required by facility policy. The facility's documentation and interviews revealed that the required reporting and investigation procedures were not followed promptly. The nurse on duty did not report the incident to the appropriate supervisor, and the staff member involved continued to work with the resident despite the care plan indicating two staff were needed. The facility's abuse prevention policy required immediate reporting and protection of residents during investigations, but these procedures were not adhered to, resulting in a failure to ensure the resident was free from abuse.
Failure to Provide Two Staff for Care as Required by Resident Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to ensure that two staff members were present to provide care to a resident with dementia and behavioral disturbances during the 3:00 PM to 11:00 PM shift, as required by the resident's care plan. The resident, who had severely impaired cognition and a history of aggression and sundowning behaviors, was care planned to have two staff for all care during this shift. On the evening in question, only one nursing assistant provided care, contrary to the care plan and the resident's care card instructions. The nursing assistant was not aware of the recent update to the care plan and reported that the change had not been communicated to him, although he acknowledged that he should have followed the care card. The incident was reported after the resident alleged that a male staff member entered the room, was rough, and hit the resident multiple times, resulting in a bruise and a small scab on the resident's hand. Facility investigation found that the resident, who was known to be combative, had struck the nursing assistant, but there was no evidence to substantiate abuse by the staff member. Interviews with staff and facility leadership confirmed that the care plan requiring two staff was not followed, and the nursing assistant should have requested assistance when the resident became agitated. The facility was unable to provide a policy on Resident Care Cards when requested.
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 170 citations issued within 25 miles in the last 12 months — including the 6 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) |
|---|---|---|---|---|
| Apple Rehab Mystic | 0.9 mi | ★★★★★ | 5 | 0 |
| Pendleton Rehabilitation And Nursing Center | 1.3 mi | ★★★★★ | 1 | 0 |
| Avalon Health Care Center At Stoneridge | 1.5 mi | ★★★★★ | 1 | 0 |
| Complete Care At Groton Regency | 3.7 mi | ★★★★★ | 13 | 0 |
| Fairview | 5.6 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Mystic Healthcare & Rehabilitation Center, Llc.
100% money-back within 48 hours.
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.