Inspection Reports for
Mystic Healthcare

The complaint involved allegations that NA #1 verbally mistreated Resident #1 on 8/27/2025 by using loud, rude, and vulgar language. The allegation was investigated and found unsubstantiated, but NA #1's communication style was inconsistent with facility expectations and resulted in termination. The facility also failed to timely report the abuse allegation to the Director of Nursing and did not remove NA #1 from the schedule to protect residents. The facility initiated staff education and quality assurance measures following the incident.

The facility failed to ensure a resident was free from verbal mistreatment by a nursing assistant whose communication style was inconsistent with facility expectations. The abuse allegation was unsubstantiated, but the staff member was terminated. Additionally, the facility failed to timely report the allegation of abuse to the Director of Nursing, which was identified as a deficiency.

The investigation was triggered by complaints regarding injuries of unknown origin to Resident #1, including burns and skin tears. The complaint was substantiated with findings of failure to assess, document, and intervene appropriately, resulting in actual harm.

The facility failed to timely review and revise the care plan after discovery of wounds, failed to perform full body skin assessments following injuries, failed to document nursing notes every shift per physician orders, and failed to implement ordered interventions such as the use of a sippy cup for drinks, resulting in actual harm to Resident #1 from burns caused by spilling hot chocolate. The facility also failed to ensure adequate supervision and accident prevention.

The complaint investigation involved multiple residents (#1, 2, 3, 4, 5, and 6) alleging verbal and physical abuse by NA #3, including rude behavior, neglect, and physical pushing. The facility suspended NA #3 pending investigation but failed to fully investigate, document grievances, provide timely support, or notify the State Agency as required.

The facility failed to ensure timely and proper investigation of abuse allegations, failed to document grievances and social service follow-ups, failed to notify the State Agency timely of abuse allegations, and failed to ensure two staff were present for care as required by the care plan for Resident #1. Several residents reported fear and mistreatment by NA #3, and the facility suspended NA #3 pending investigation but did not fully investigate or report all allegations appropriately.

The investigation was related to complaints CT #26075 and #26188.

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.

The facility was found deficient in multiple areas including failure to review and revise care plans quarterly, lack of physician's order for continuous oxygen use, failure to change oxygen tubing as ordered, missed signatures on controlled substance audits, presence of expired medications in medication carts and storage rooms, and inadequate cleaning of medication carts.

The complaint investigation found that Resident #1 exited the facility without staff knowledge due to a malfunctioning wanderguard alarm on the D-Wing door. The alarm was sounding but was barely audible, preventing staff from hearing it. The resident was found outside on the sidewalk and returned safely with no injuries. The facility assigned staff to monitor the door until repairs were completed.

The facility failed to provide adequate supervision to prevent Resident #1, who was identified as an elopement risk, from leaving the building unescorted due to a malfunctioning wanderguard alarm on the back door. Staff were unaware of the resident's exit until notified by another resident, and the door alarm was found to be non-audible due to malfunction.

Complaint investigation #36041 was conducted. The complaint was substantiated with findings of noncompliance related to resident elopement risk and door alarm malfunctions.

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.

The survey was complaint-driven under ACTS Reference Numbers CT00030803 and CT00030868.

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.

The investigation was triggered by complaint numbers #30803 and #30868. Violations were substantiated as noted in the attached violation letter dated October 10, 2021.

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.

The facility was found deficient in multiple areas including failure to provide care per resident preferences, medication administration errors with late medication delivery, failure to apply physician-ordered anti-embolism stockings, inadequate supervision during smoking and meals, unsafe resident transfers leading to falls, failure to change and date oxygen tubing per orders, inaccurate medical record documentation, and inadequate infection prevention practices including improper sanitization of glucometers and incomplete water management documentation.

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.

The visit was complaint-related, triggered by allegations of failure to follow care plans, inadequate treatment and care, pressure ulcer prevention failures, accident hazards, and nutritional neglect. Substantiation status is not explicitly stated.

The facility was found deficient in multiple areas including failure to promptly intervene when a resident was coughing during dining, failure to monitor and document vascular access site, failure to complete RN assessment after an incident, inadequate pressure ulcer prevention and care, failure to prevent falls and provide adequate supervision, and failure to follow up on dietitian recommendations and notify of significant weight loss.

Complaint #24555 triggered the investigation and certification survey.

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 #CT#24555 triggered the investigation. The complaint was substantiated with citations issued.

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.