Inspection Reports for Mystic Healthcare
475 High St, Mystic, CT 06355, United States, CT, 06355
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 11, 2025, found that previously cited violations related to complaint #43704 had been corrected and staffing met state requirements. Earlier inspections showed a pattern of deficiencies primarily involving resident care issues such as timely clinical assessments, supervision to prevent elopement, and medication management. Complaint investigations were mostly unsubstantiated except for a few substantiated cases involving resident safety and medication concerns, including a notable past finding of failure to prevent medication misappropriation and inadequate responses to residents’ health changes. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have addressed recent deficiencies, showing improvement in compliance over the latest inspection period.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
4.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% better than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
84% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Census: 84
Capacity: 100
Deficiencies: 0
Jun 11, 2025
Visit Reason
The visit was conducted as a follow-up to review the implementation of the plan of correction for complaint #43704 and the violation letter dated May 13, 2025.
Findings
Staffing met the minimum requirements for the State of Connecticut Public Health Code for the two-week period reviewed. Violations #1a, #2a, #3a, and #4a were reviewed and corrected as of May 29, 2025.
Complaint Details
The visit was related to complaint #43704. The violations cited in the complaint were reviewed and found to be corrected.
Report Facts
Licensed Bed Capacity: 100
Census: 84
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Gaffney | Person Administrator | Personnel contact during the inspection |
| Melissa Cope | Report submitted by |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 100
Deficiencies: 0
May 29, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint Investigations #44534.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Complaint Details
Complaint Investigation #44534 was the reason for the visit. No violations were found, indicating the complaint was not substantiated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amber Gaffney | Administrator | Personnel contacted during the inspection. |
| Serena Trudel | DON | Personnel contacted during the inspection. |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 100
Deficiencies: 0
Apr 17, 2025
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigation #43704 and to identify any violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection. The report references an attached violation letter but does not detail specific findings within this document.
Complaint Details
The visit was triggered by Complaint Investigation #43704. Violations were identified during the inspection.
Report Facts
Census: 88
Total Capacity: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Serena Trudel | DNS | Personnel contacted during inspection |
| Allison Benson | Nurse Consultant | Report submitted by |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 100
Deficiencies: 0
Apr 2, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to complaints #41607 and #43459.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Complaint Details
Complaint investigation for complaints #41607 and #43459; violations were not substantiated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amber Gaffney | Administrator | Personnel contacted during the inspection. |
| Terri Anderson-Murray | RN | Report submitted by. |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 100
Deficiencies: 0
Feb 13, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint Investigation #42871 and to identify any violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection, as noted in the attached violation letter.
Complaint Details
Complaint Investigation #42871 was the basis for this inspection. Violations were identified during the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amber Gaffney | Administrator | Personnel contacted during the inspection |
| Cynthia Charette | DNS | Personnel contacted during the inspection |
| Allison Benson | Nurse Consultant | Report submitted by |
Inspection Report
Plan of Correction
Deficiencies: 1
Jan 24, 2025
Visit Reason
A remote investigation was completed with Mystic Healthcare & Rehabilitation Center, LLC on January 24, 2025, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting multiple investigations.
Findings
The facility failed to ensure a dehydration assessment was completed timely and failed to notify the physician/APRN timely for a resident with known poor fluid intake and loose stools, leading to a resident's transfer to the hospital with sepsis. The report details clinical record reviews, nursing notes, and interviews identifying these failures.
Complaint Details
The investigation was related to complaints CT #26075 and #26188.
Deficiencies (1)
| Description |
|---|
| Failure to ensure a dehydration assessment was completed timely and failure to notify the physician/APRN timely for a resident with known poor fluid intake and loose stools. |
Report Facts
Date of Compliance: Mar 30, 2025
Complaint Numbers: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maureen Golas-Markure | Supervising Nurse Consultant | Signed the notice letter regarding the plan of correction. |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 100
Deficiencies: 0
Mar 12, 2024
Visit Reason
The inspection was conducted as a complaint investigation referenced by complaint #37829.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Complaint Details
Complaint investigation #37829 was conducted and found no violations; the complaint was not substantiated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Desell | Administrator | Personnel contacted during the inspection. |
| Nicole Loving | DNS | Personnel contacted during the inspection. |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 100
Deficiencies: 0
Feb 6, 2024
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigation #37187.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Complaint Details
Complaint Investigation #37187 was reviewed and found to have no violations substantiated at the time of inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Desell | Administrator | Personnel contacted during the inspection. |
| Nicole Loving | Director of Nursing | Personnel contacted during the inspection. |
| Aneta Predka | NC / RN | Signature of FLIS staff and report submitter. |
Inspection Report
Renewal
Census: 85
Capacity: 100
Deficiencies: 0
Nov 8, 2023
Visit Reason
The inspection was conducted as a renewal licensing inspection for the facility.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Desell | Administrator | Personnel contacted during the inspection |
| Nicole Loving | Nurse | Personnel contacted during the inspection |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 100
Deficiencies: 1
Oct 24, 2023
Visit Reason
An unannounced visit was conducted on October 24, 2023, for the purpose of a complaint investigation at Mystic Healthcare & Rehabilitation Center, LLC.
Findings
Violations of the General Statutes of Connecticut and/or regulations were identified during the inspection, specifically related to resident elopement risks and door alarm malfunctions. The facility lacked proper supervision policies to prevent residents from leaving without staff knowledge.
Complaint Details
Complaint investigation #36041 was conducted. The complaint was substantiated with findings of noncompliance related to resident elopement risk and door alarm malfunctions.
Deficiencies (1)
| Description |
|---|
| Failure to prevent Resident #1 from exiting the facility without staff knowledge due to malfunctioning wander guard alarm on the back door and lack of supervision policies. |
Report Facts
Licensed Bed: 100
Census: 85
Resident Elopement Evaluation Score: 8
Resident Elopement Risk Score: 1
Number of Doors with Wanderguard System: 3
Date of Compliance: Dec 5, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Desell | Administrator | Administrator interviewed regarding door malfunction and supervision. |
| Nicholas Tomczyk | Nurse Consultant | Report submitted by. |
| Maureen Golas Markure | Supervising Nurse Consultant | Signed the notice letter regarding complaint #36041. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Sep 27, 2021
Visit Reason
A Complaint Investigation Survey was conducted on September 23 and 27, 2021 at Mystic Healthcare & Rehabilitation Center, LLC to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Findings
The facility was found deficient in multiple areas including failure to notify medical staff of medication refusals, misappropriation and exploitation of resident medications by staff, failure to monitor and manage resident bowel movements per protocol, failure to reassess oxygen saturation after condition changes, and failure to reconcile medications on admission resulting in omitted medications.
Complaint Details
The survey was complaint-driven under ACTS Reference Numbers CT00030803 and CT00030868.
Severity Breakdown
Level E: 2
Level D: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to notify medical staff of Resident #1's continuous refusals of taking Ritalin medication. | Level E |
| Failed to ensure medications were not misappropriated for staff use and failed to prevent exploitation of Resident #1 by staff selling prescription medication. | Level D |
| Failed to monitor and implement bowel protocol for Resident #1 at risk for constipation. | Level D |
| Failed to reassess Resident #1's oxygen saturation level following a change in condition. | Level D |
| Failed to reconcile medication list on admission for Resident #2 resulting in omitted medications (Lasix and Metoprolol) for nearly a month. | Level E |
Report Facts
Medication refusals: 20
Xanax tablets found: 11
Medication omission days: 29
Medication omission days: 30
Cough syrup administrations: 14
Bowel movement gap: 11
Bowel movement gap: 12
Oxygen saturation: 88
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Nursing Supervisor Registered Nurse | Named in medication misappropriation and medication reconciliation omission findings. |
| LPN #1 | Licensed Practical Nurse | Found illicit Xanax tablets in Resident #1's room and reported incident. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding multiple deficiencies including medication refusals, misappropriation, bowel management, oxygen monitoring, and medication reconciliation. |
| MD #2 | Medical Doctor | Attending physician for Resident #1 and Resident #2, interviewed regarding notification failures and medication reconciliation. |
| APRN #1 | Advanced Practice Registered Nurse | Notified about medication refusals and medication misuse, but was not informed timely. |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 100
Deficiencies: 5
Sep 23, 2021
Visit Reason
Unannounced visits were made to Mystic Healthcare & Rehabilitation Center on September 23 and 27, 2021 by the Department of Public Health for the purpose of conducting a complaint investigation related to violations of Connecticut State regulations.
Findings
Multiple violations were identified involving medication administration, misappropriation of medications, failure to monitor bowel movements and respiratory status, and medication reconciliation errors. The facility failed to notify medical staff of residents' refusals of medication and failed to prevent misappropriation of medications by staff.
Complaint Details
The investigation was triggered by complaint numbers #30803 and #30868. Violations were substantiated as noted in the attached violation letter dated October 10, 2021.
Deficiencies (5)
| Description |
|---|
| Failure to notify medical staff of Resident #1's continuous refusals of medication, including Ritalin. |
| Failure to ensure medications were not misappropriated for Resident #1, including sale of Xanax by a nurse. |
| Failure to monitor and implement bowel protocol for Resident #1 with impaired mobility and constipation risk. |
| Failure to reassess and document Resident #1's oxygen saturation and respiratory status following condition changes. |
| Failure to reconcile medication list for Resident #2, resulting in omitted medications and medication errors. |
Report Facts
Census: 83
Total Capacity: 100
Inspection Dates: September 23 and 27, 2021
Medication refusals: 20
Medication misappropriation: 11
Medication misappropriation: 4
Bowel movement tracking: 12
Medication reconciliation days: 29
Medication reconciliation days: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ken Kopchik | Administrator | Named as facility administrator in report |
| Nicole Loving | Director of Nursing (DNS) | Named as Director of Nursing and responsible for compliance with plan of correction |
| Karen Gworek | Supervising Nurse Consultant | Author of important notice letter regarding violations and plan of correction |
| RN #1 | Registered Nurse | Identified in medication misappropriation and failure to notify medical staff |
| LPN #1 | Licensed Practical Nurse | Found with napkin containing Xanax tablets and involved in medication misappropriation |
| MD #2 | Medical Doctor | Attending physician interviewed regarding medication refusals and oxygen monitoring |
| APRN #1 | Advanced Practice Registered Nurse | Interviewed regarding medication refusals and respiratory assessments |
Inspection Report
Abbreviated Survey
Census: 57
Capacity: 100
Deficiencies: 1
May 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to determine compliance with 42 CFR §483.80 Infection Control regulations for Long Term Care Facilities.
Findings
The facility failed to ensure appropriate infection control practices were implemented for COVID positive residents, including improper use of PPE by staff and failure to ensure residents wore masks during transport. Re-education and audits were planned to address these issues.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure appropriate infection control practices for COVID positive residents, including staff not wearing required PPE (gown, gloves, face shield) and residents not wearing masks during transport. | SS=D |
Report Facts
Capacity: 100
Census: 57
Staff observed: 3
Audit frequency: 2.5
Audit frequency: 1.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed not wearing appropriate PPE when entering COVID positive resident room |
| LPN #2 | Licensed Practical Nurse | Observed not wearing appropriate PPE and improper mask use in COVID positive resident room |
| NA #1 | Nursing Assistant | Observed transporting COVID positive resident without mask on resident |
| DON | Director of Nursing | Provided statements on PPE requirements and re-education plans |
| Nurse #1 | Nurse | Re-educated on droplet/contact precautions and PPE use |
| Nurse #2 | Nurse | Re-educated on droplet/contact precautions and PPE use |
| CNA #1 | Certified Nursing Assistant | Re-educated on preventing spread of COVID-19 and ensuring residents wear masks during transport |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Apr 28, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this COVID-19 focused survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Apr 23, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this COVID-19 focused survey.
Inspection Report
Routine
Deficiencies: 0
Apr 23, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this survey.
Inspection Report
Plan of Correction
Deficiencies: 7
Apr 4, 2019
Visit Reason
Unannounced visits were made to Mystic Healthcare & Rehabilitation Center for the purpose of conducting an investigation and a certification survey, resulting in a notice of noncompliance and requirement to submit a plan of correction.
Findings
The report details multiple violations of Connecticut State Regulations related to medical records, nursing staff interventions, resident care, and facility policies. The facility failed to ensure accurate coding, timely interventions, proper monitoring, and adequate documentation, resulting in risks to resident safety and care quality.
Complaint Details
Complaint #24555 triggered the investigation and certification survey.
Deficiencies (7)
| Description |
|---|
| Failure to ensure accurate PASRR coding and assessment for residents with mental illness. |
| Failure to intervene timely when a resident was coughing while drinking fluids, risking aspiration. |
| Failure to monitor vascular access sites and complete RN assessments immediately after incidents. |
| Failure to provide care according to professional standards to prevent pressure ulcers. |
| Failure to prevent falls and injuries related to Hoyer lift transfers and inadequate supervision. |
| Failure to follow proper turning and repositioning protocols to prevent pressure ulcers. |
| Failure to follow weight loss monitoring and notification policies for residents. |
Report Facts
Plan of correction submission deadline: May 17, 2019
Date of inspection visit: Apr 4, 2019
Audit frequency: 1
Audit duration: 90
Compliance review period: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Norma Schuberth | Supervising Nurse Consultant | Signed letter directing plan of correction submission and overseeing complaint #24555. |
| Kenneth Kopchik | Administrator | Named as facility administrator receiving the notice and plan of correction instructions. |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 100
Deficiencies: 7
Apr 1, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to complaint #CT#24555, with citations issued as a result of the inspection.
Findings
The facility was found to have multiple violations including failure to intervene timely when a resident was coughing, inadequate monitoring of vascular access sites, failure to prevent falls resulting in injury, and failure to provide care to prevent pressure ulcers. Plans of correction were required for these deficiencies.
Complaint Details
Complaint #CT#24555 triggered the investigation. The complaint was substantiated with citations issued.
Deficiencies (7)
| Description |
|---|
| Failure to intervene in a timely manner while a resident was coughing after drinking fluids. |
| Failure to ensure an RN assessment was immediately completed after an incident involving a resident with a vascular access site. |
| Failure to provide care according to professional standards to prevent the development of a pressure ulcer. |
| Failure to ensure adequate supervision and interventions to prevent falls resulting in a femur fracture. |
| Failure to investigate and provide adequate supervision to prevent falls with resulting injury. |
| Failure to follow up on dietician recommendations and monitor nutritional status. |
| Failure to notify dietitian and physician of continued weight loss and failure to monitor weight changes. |
Report Facts
Licensed Bed Capacity: 100
Census: 79
Citation Number: 2019
Date(s) of onsite inspection: Apr 1, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ken Kopchik | Administrator | Named in relation to complaint investigation and findings |
| Marsha Murphy | DNS | Named in relation to complaint investigation and findings |
| Norma Schuberth | Supervising Nurse Consultant | Signed complaint investigation notice |
Report
Nov 25, 2025
File
complaint-inspection_2025-11-25.pdf
Report
Apr 17, 2025
File
complaint-inspection_2025-04-17.pdf
Report
Feb 14, 2025
File
complaint-inspection_2025-02-14.pdf
Report
Nov 8, 2023
File
health-inspection_2023-11-08.pdf
Report
Oct 24, 2023
File
complaint-inspection_2023-10-24.pdf
Report
Aug 2, 2021
File
health-inspection_2021-08-02.pdf
Report
Apr 4, 2019
File
health-inspection_2019-04-04.pdf
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