Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pendleton Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Two residents who reported abuse did not have timely nursing assessments documented in their clinical records as required by facility policy. Although assessments were reportedly performed and incidents were investigated, the necessary documentation was either missing or entered late, resulting in incomplete records of the events and the facility's response.
A resident with a history of subdural hematoma and on anticoagulation experienced multiple unwitnessed falls. After the initial fall, neurological checks were performed as required, but following a subsequent unwitnessed fall, staff did not restart neurological checks at the mandated intervals according to facility policy. Documentation and staff interviews confirmed that the required neurological assessments were not completed after each fall.
A resident with multiple diagnoses experienced swelling and pain in the left hand, but the facility failed to notify the physician as required by policy. Despite the symptoms being documented in nursing notes, staff interviews revealed that the physician was not informed, which was a deviation from the facility's procedures for handling changes in a resident's condition.
A facility failed to include necessary monitoring and emergency actions in the care plan for a resident receiving anticoagulant medication. Despite daily administration of Coumadin, the care plan lacked interventions for monitoring side effects, contrary to facility policy. The DNS confirmed the care plan should have addressed these needs.
Two residents were found with medications at their bedside without proper authorization or assessments for self-administration. One resident with COPD had respiratory medications left by nurses for convenience, while another resident with kidney disease had a red liquid and ointment left in their room. The facility's policy requires an interdisciplinary team assessment and a physician's order for self-administration, which were not in place for these residents.
A resident with cognitive impairment and mobility issues did not receive scheduled showers over a three-month period, despite being scheduled for twice-weekly showers. Facility documentation lacked reasons for missed showers, and staff interviews revealed confusion about documentation protocols. The facility's policy requires necessary services for residents unable to perform ADLs, which was not followed.
A resident with COPD did not receive medications as prescribed due to discrepancies in administration and documentation. The resident's medications were left in their room for convenience, and the MAR showed inconsistencies with the pharmacy's dispensed quantities. Nursing staff failed to reorder medications appropriately, leading to a shortage and non-compliance with the facility's medication administration policy.
A resident, admitted with conditions including dementia and COPD, requested a pneumococcal vaccine upon admission. Despite consent from the resident's legal representative, the facility failed to administer the PCV 20 vaccine and did not communicate the request to the primary physician. The facility's policy required offering immunizations unless contraindicated, but the oversight in communication led to the deficiency.
A resident with multiple diagnoses had a nebulizer mask and tubing improperly stored in their room, despite not having received a treatment in several months. The prescribed Albuterol Sulfate solution was not administered from November 2024 to January 2025, and an LPN confirmed no treatments since July 2023. The facility's policy required equipment to be stored in a zip lock bag when not in use, which was not followed.
A facility failed to accurately code MDS assessments for a resident with end-stage kidney disease, heart failure, and diabetes, omitting the resident's hemodialysis treatments. Despite having a physician's order for dialysis three times a week, four MDS assessments did not reflect this treatment. The MDS Coordinator acknowledged the oversight but could not explain the reason for the error, despite the facility's comprehensive assessment process.
A resident with a fractured tibia, diabetes, and morbid obesity developed pressure ulcers that were not promptly reported to the physician. Despite initial skin checks showing no issues, subsequent checks identified abrasions. The facility failed to document and treat the pressure ulcers as per recommendations, and staff were unaware of the worsening condition. The DNS was not informed of medical appointments and consultation reports, leading to a failure in notifying the physician and the resident's family.
A facility failed to properly assess, monitor, and treat a resident's pressure ulcer, leading to the development of new pressure ulcers. Despite physician orders and documented skin checks, new abrasions and pressure ulcers were later identified, indicating inconsistent and inadequate monitoring and documentation.
Failure to Timely Document Nursing Assessments Following Abuse Allegations
Penalty
Summary
The facility failed to ensure that nursing assessments were completed and documented in the clinical records at the time allegations of abuse were reported for two of three sampled residents. In the first case, a resident with cognitive impairment and a history of non-compliance reported to a family member that a nurse aide had physically abused them, resulting in visible bruising on both forearms. Although the incident was reported and an assessment was said to have been performed, there was no contemporaneous nurse's note or documentation of the assessment in the clinical record. A late entry was created by the DON two weeks after the incident, but the original assessment and documentation were missing at the time of the event. In the second case, another resident with psychiatric diagnoses reported to a social worker that a nurse aide had physically and verbally abused them. The facility's incident report indicated that there were no injuries and that appropriate notifications and an investigation were initiated. However, a review of the clinical record revealed that no nurse's note or assessment was documented following the allegation. The DON later acknowledged that, despite personally assessing the resident and completing paperwork, she did not document the assessment or the allegation in the clinical record at the time of the incident. Facility policy requires that each resident's medical record contain accurate, complete, and timely documentation of all assessments, observations, and services provided, to be completed no later than the shift in which the event occurred. In both cases, the required documentation was not entered into the clinical record as stipulated by policy, resulting in incomplete records regarding the residents' experiences and the facility's response to the abuse allegations.
Failure to Complete Neurological Checks After Multiple Unwitnessed Falls
Penalty
Summary
The facility failed to follow its own policy regarding neurological checks after unwitnessed falls for a resident with significant risk factors, including a history of subdural hematoma, atrial fibrillation, and use of anticoagulation. The resident was identified as being at risk for falls due to confusion and disorientation, and the care plan included interventions for fall prevention. On the day in question, the resident experienced multiple unwitnessed falls, each requiring neurological assessments as per facility protocol. After the first unwitnessed fall, neurological checks were initiated and documented at the required intervals. However, following a second unwitnessed fall, the neurological checks were not restarted as required by facility policy. Instead, the checks continued at the previous schedule, resulting in missed assessments at the mandated half-hour intervals after the second fall. Staff interviews confirmed that the expectation was to initiate a new set of neurological checks after each unwitnessed fall, but this was not done after the second incident. Documentation review and staff interviews further revealed that the neurological assessment protocol was not consistently followed after subsequent falls. The Director of Nursing confirmed that the facility policy required neurological checks to be restarted after each unwitnessed fall, but this was not adhered to in this case. The medical record lacked evidence of the required frequency of neurological checks after the second fall, and staff were not aware that the protocol had not been followed as outlined in the facility's neurological assessment form.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician when a resident experienced symptoms of pain and swelling in the left hand. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, gout, and atrial fibrillation, was cognitively intact and required maximum assistance with certain activities of daily living. Despite the resident's left hand showing signs of edema, redness, and impaired range of motion, there was no documentation that the physician was informed of these changes. Interviews with staff confirmed that the physician should have been notified, especially since the symptoms were significant enough to be noted in nursing records. The deficiency was identified through observations, clinical record reviews, and staff interviews. The facility's policy mandates prompt consultation with the resident's physician when there is a change in condition that requires notification. However, the policy was not followed in this case, as the physician was not informed of the resident's persistent swelling and pain, which could have necessitated a reevaluation of interventions and treatments. The lack of communication with the physician was a clear deviation from the facility's established procedures for handling changes in a resident's condition.
Care Plan Deficiency for Anticoagulant Monitoring
Penalty
Summary
The facility failed to ensure that the care plan for a resident receiving anticoagulant medication included necessary monitoring for possible side effects and actions to take in case of an emergency. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, gout, and atrial fibrillation, was cognitively intact and required maximum assistance with certain activities of daily living. Despite being administered Coumadin daily, the care plan did not reflect the resident's use of anticoagulant medication or include interventions to monitor for adverse effects such as bleeding, hemorrhage, or changes in hematocrit or blood pressure. The facility's policy for high-risk medications, including anticoagulants, mandates that the care plan should alert staff to monitor for adverse consequences and include interventions to minimize risks. However, the care plan dated 10/31/24 for the resident did not comply with this policy. The Director of Nursing Services confirmed that the care plan should have acknowledged the use of anticoagulant medication and included necessary precautions. This oversight was identified during a review of the clinical record, facility policies, and interviews conducted as part of the survey process.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure that medications were administered according to acceptable standards of practice for two residents. Resident #22, who has diagnoses including respiratory failure and COPD, was found with medications at the bedside without a physician's order for self-administration or a completed self-administration assessment. The medications included Advair Diskus and Fluticasone Propionate, which were supposed to be administered by the nursing staff. The resident reported that the medications were left by the nurses for convenience, and the LPN confirmed that she assumed the resident had an order for self-administration. However, the Nursing Unit Manager and the DNS confirmed that there was no such order or assessment in place. Resident #101, who has diagnoses including kidney disease and high blood pressure, was also found with medications at the bedside without proper authorization. A medication cup containing a red liquid and mupirocin ointment were left in the resident's room. The resident was moderately cognitively impaired and did not want to self-administer medications, as noted in the nurse's quarterly assessment. The DNS confirmed that self-administration assessments are required, and medications should be stored in a lock box if a resident is authorized to self-administer. The facility's policy on self-administration of medications requires an interdisciplinary team assessment and a physician's order before a resident can self-administer medications. Both residents were found with medications at their bedside without these requirements being met, indicating a failure to adhere to the facility's policy and professional standards of quality care.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #44, received showers as scheduled, which is a deficiency in providing necessary care for activities of daily living (ADLs). Resident #44, who has diagnoses including muscle weakness and difficulty walking, was identified as moderately cognitively impaired and required assistance with bathing. The care plan specified that the resident should receive showers on certain days and shifts. However, interviews and documentation reviews revealed that Resident #44 only received two showers over a three-month period, despite being scheduled for showers twice weekly. The nurse aide documentation did not provide reasons for the missed showers, and the resident did not refuse showers according to staff interviews. Interviews with staff, including a nurse aide and the Director of Nursing Services (DNS), highlighted a lack of clarity and adherence to documentation protocols. The nurse aide indicated that the care tasks prompt them to document if a shower is given, refused, or not applicable, but there was confusion about what 'N/A' meant in the documentation. The DNS acknowledged that if a resident does not receive a shower as scheduled, it should be documented, and the resident should be reapproached. The facility's policy on ADLs states that residents unable to perform these activities should receive necessary services to maintain hygiene, which was not adhered to in this case.
Medication Administration Deficiency for a Resident with COPD
Penalty
Summary
The facility failed to ensure that medications were administered as prescribed by the physician for Resident #22, who had diagnoses including respiratory failure, COPD, asthma, and dependence on supplemental oxygen. The resident was cognitively intact and required moderate assistance for certain activities but was independent with toileting hygiene and bed mobility. The care plan included administering medications as ordered and monitoring for respiratory distress. However, observations and interviews revealed discrepancies in medication administration and documentation. During an observation, it was found that Resident #22 had medications in a plastic bag on the nightstand, which included Advair Diskus and Fluticasone Propionate, with some medications not being administered as prescribed. The resident reported last using these medications about a month ago, and it was noted that the nurses left the medication there for convenience. The medication cart and storage room did not contain the required medications for the resident, and the Medication Administration Record (MAR) showed inconsistencies with the actual dispensed quantities from the pharmacy. Interviews with nursing staff and the pharmacy technician revealed that the resident's medications were not reordered appropriately, and the MAR was signed without proper administration. The pharmacy had not received a refill order for the medications since the last dispense date, leading to a shortage. The facility's policy required medications to be administered by licensed nurses and observed, but this was not followed, resulting in the resident not receiving medications as ordered, potentially affecting their health condition.
Failure to Administer Requested Pneumococcal Vaccine
Penalty
Summary
The facility failed to administer the pneumococcal vaccine to a resident who had requested it upon admission. The resident, who was cognitively intact and had a history of cervical disc disorder with myelopathy, unspecified dementia, and COPD with exacerbation, was admitted in June 2024. Despite having received previous pneumococcal vaccinations (PCV 13 in 2015 and PPV23 in 2017), the resident's legal representative consented to the administration of the PCV 20 vaccine in June 2024. However, the facility did not administer the vaccine, nor did they document any change in the resident's decision. Interviews with the Infection Preventionist Nurse and the Regional Clinical Manager revealed that the responsibility for reviewing immunization consent forms and obtaining physician orders for vaccines lay with the Infection Preventionist Nurse. Despite this, the resident's request for the PCV 20 vaccine was not communicated to the primary physician, who confirmed he would have approved the vaccine if informed. The facility's policy stated that residents should be offered pneumococcal immunizations unless contraindicated or already immunized, and that immunizations could be administered under physician-approved standing orders. The oversight in communication and failure to follow through with the resident's vaccination request led to the deficiency.
Improper Storage of Nebulizer Equipment
Penalty
Summary
The facility failed to ensure proper storage and labeling of nebulizer equipment for a resident diagnosed with high blood pressure, obesity, and depression. The resident, who was cognitively intact and required maximum assistance with daily activities, had a nebulizer mask and tubing hanging from a light fixture above their bed, attached to a nebulizer machine in the bedside table. The resident reported not having received a breathing treatment in several months and could not recall the last time the nebulizer was used. A review of the Medication Administration Records revealed that the prescribed Albuterol Sulfate solution for nebulizer use had not been administered from November 2024 to January 2025. An LPN confirmed that the resident had not received a nebulizer treatment since July 2023. Despite the lack of use, the nebulizer equipment remained in the resident's room, contrary to the facility's Nebulizer Therapy policy, which required equipment to be stored in a zip lock bag when not in use. The order for the nebulizer medication was eventually discontinued, but no explanation was provided for the oversight in equipment management.
Inaccurate MDS Coding for Dialysis
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for a resident with end-stage kidney disease, heart failure, and diabetes were accurately coded to reflect the resident's hemodialysis treatments. The resident had a physician's order for hemodialysis three times a week from February 2024 through January 2025. However, four MDS assessments, including two admission and two quarterly assessments, did not indicate that the resident was receiving hemodialysis treatments. An interview with the MDS Coordinator (RN #3) revealed that dialysis should have been coded on the MDS assessments, but RN #3 could not provide a reason for the omission. The MDS assessment process, as described by RN #3, involves reviewing various sources of information, including nurses' notes, physician orders, and documentation from the hospital, as well as interviewing the resident. The facility's policy on MDS 3.0 Completion emphasizes a comprehensive assessment process to identify care needs and develop an interdisciplinary care plan. Despite this, the assessments failed to document the resident's dialysis needs, as required by RAI guidance.
Failure to Notify Physician of Pressure Injuries
Penalty
Summary
The facility failed to notify the physician of pressure injuries for a resident who was admitted with a fracture of the left tibia, diabetes type II, and morbid obesity. The resident's care plan included monitoring skin integrity and circulation around the cast every shift. Initial skin checks showed no skin alterations, but subsequent checks identified new skin impairments, including abrasions on the left heel and toes. Despite these findings, the facility did not notify the physician promptly, and the resident's condition worsened, leading to pressure ulcers that were later identified by an outpatient orthopedic surgeon and wound clinic. The resident's medical record lacked documentation of the pressure ulcers identified by the orthopedic surgeon and wound clinic. The facility's wound care nurse and other staff members failed to monitor and treat the pressure ulcers as per the outpatient wound clinic's recommendations. Interviews with staff revealed that they were unaware of the resident's worsening condition and did not follow proper procedures for notifying the physician and documenting the resident's skin impairments. The facility's Director of Nursing Services (DNS) was not aware of the resident's medical appointments and consultation reports. The process for handling post-visit reports was not followed, resulting in the physician not being notified of the resident's pressure ulcers. The facility's policy on notification of changes was not adhered to, leading to a failure in consulting with the resident's physician and notifying the resident's family member or legal representative when there was a significant change in the resident's condition.
Failure to Properly Monitor and Treat Pressure Ulcers
Penalty
Summary
The facility failed to properly assess, monitor, and treat a resident's pressure ulcer, leading to the development of new pressure ulcers. The resident, who had a history of diabetes, venous insufficiency, and morbid obesity, was admitted with a fractured left tibia and had a cast placed on the left lower extremity. Despite physician orders to monitor skin integrity under and around the cast every shift, the facility's documentation showed inconsistent and inadequate skin checks, with some staff unable to recall specific details of their assessments. On multiple occasions, skin checks were documented as showing no new issues, but on 7/5/23, new abrasions were noted on the resident's left heel, toes, and dorsal foot. These areas were treated with skin prep as ordered by the physician. However, subsequent documentation failed to identify any further skin impairments until an outpatient orthopedic consultation on 7/13/23 revealed pressure ulcers on the resident's dorsal midfoot and posterior heel, with the latter showing eschar. This discrepancy indicates a failure in the facility's monitoring and documentation processes. Interviews with various staff members revealed a lack of consistent practice in removing the cam boot to check the resident's skin thoroughly. The wound RN and other nursing staff were not aware of the severity of the pressure ulcers until much later, and the facility's documentation did not reflect the outpatient wound clinic's recommendations for treatment. The Director of Nursing Services (DNS) was also unaware of the resident's medical appointments and consultation reports, highlighting a breakdown in communication and follow-up within the facility.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mystic
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avalon Health Care Center At Stoneridge | 0.3 mi | ★★★★★ | 1 | 0 |
| Mystic Healthcare & Rehabilitation Center, Llc | 1.3 mi | ★★★★★ | 20 | 1 |
| Apple Rehab Mystic | 1.4 mi | ★★★★★ | 5 | 0 |
| Complete Care At Groton Regency | 5 mi | ★★★★★ | 13 | 0 |
| Royal Of Westerly Nursing Center | 6.4 mi | ★★★★★ | 9 | 0 |
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