Mystic Healthcare & Rehabilitation Center, LLC

In the surveyor’s words

From the most serious findings on record at Mystic Healthcare & Rehabilitation Center, LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 19, 2026

  Based on clinical record reviews, facility documentation, facility policies and interviews for four (4) of four (4) sampled residents (Residents #1, #2, #3, and #4), reviewed for a safe environment, the facility failed to ensure the environment was safe from accidents or hazards, when a food cart containing meal trays was stored outside of the locked kitchen door overnight and was accessible to cognitively impaired residents, who were prescribed modified diets and had wandering behaviors, which created a choking hazard. Additionally, one (1) of four (4) sampled residents (Resident #1) experienced a choking episode requiring the Heimlich maneuver after accessing food from the unattended tray chart. This failure resulted in the finding of Immediate Jeopardy. […]

• Immediate jeopardy, isolatedF678Feb 2, 2022

  Based on a clinical record review, review of facility documentation, staff interviews and review of the facility policy for one sampled resident (Resident #1) who was reviewed for change in condition, the facility failed to ensure that life saving measures were provided when the resident was found to be unresponsive and not breathing which resulted in the finding of Immediate Jeopardy. The finding includes: Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's medical record identified an Advance Directives document signed and dated [DATE] that identified Resident #1 desired Cardiopulmonary Resuscitation (CPR). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was cognitively intact. […]

• Actual harm, isolatedF689May 6, 2026

  Based on review of the clinical record, facility documentation, facility policies, and interviews, for one (1) of three (3) sampled residents (Resident #1), who required the assistance of two staff for transfers, the facility failed to transfer the resident according to the plan of care resulting in a fall with major injury (left hip fracture) requiring surgical intervention. The findings include:Resident #1's diagnoses included hemiplegia and hemiparesis following a cerebral infarct affecting left side, abnormality of gait, muscle weakness, and bradycardia.The physician's order dated 2/9/26 directed an assist of two (2) using the ETAC [NAME] (turn aid with a functional design that offers safe patient turning with standing support during transfers).The quarterly Minimum Data Set assessment… […]

• Actual harm, isolatedF689Apr 17, 2025

  Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for injuries of unknown origin, the facility failed to ensure the resident was free from accidents resulting in sustaining several burn wounds from a hot beverage spill and the failure to implement an ordered intervention to prevent further injury. The findings include: Resident #1's diagnoses included dementia without behavioral disturbances, generalized muscle weakness and polyneuropathy (peripheral nerve disorder that causes multiple nerves throughout the body to malfunction at the same time which can cause numbness, pain, tingling or a burning sensation). […]

• No harm, potential for more than minimal, patternF692Jan 14, 2026

  Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 3 of 4 residents (Resident #3, Resident #11, and Resident #78) reviewed for nutrition, the facility failed to obtain admission weights, monthly weights and re-weights per the facility policy. The findings include: Resident #3's diagnoses included type 2 diabetes, malignant neoplasm of the lower stomach, and atrial fibrillation (irregular heart rhythm). The Minimum Data Set assessment (MDS) assessment dated [DATE] identified Resident #3 had a Brief Interview of Mental Status of 8, indicating moderate cognitive impairment. The Resident Care Plan in effect from 7/13/25 through 1/14/26 identified dysphagia. […]