Cycle 1
Health 2025-01-23 · Fire 2025-01-23
10 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Mystic, CT
Pendleton Rehabilitation And Nursing Center
5-star overall rating with 4-star inspections with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
44 Maritime Drive, Mystic, CT
(860) 572-1700
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
114
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Atlas Healthcare
Operator or chain grouping
Approved since
1991-02-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.65
Registered nurse staffing
LPN hours / resident day
0.89
Licensed practical nurse staffing
Aide hours / resident day
2.18
Nurse aide staffing
Weekend hours
3.42
Weekend nurse staffing
RN turnover
32%
Annual RN turnover
Total nurse turnover
42%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.5
0.3 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
87.5%
9 pts better
|
93.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.5%
6.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.8% |
3.4%
1.4 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 8.5% |
17.1%
8.6 pts better
|
11.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 6.1% |
6.4%
0.3 pts better
|
5.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.9% |
17.3%
4.6 pts worse
|
19.6%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 14.8% |
19.4%
4.6 pts better
|
16.7%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.9% |
18.1%
7.2 pts better
|
16.3%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.5% |
18.4%
7.9 pts better
|
14.9%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.7%
0.9 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.1% |
24.8%
3.3 pts worse
|
19.8%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
4.4%
1.4 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.3% |
70.5%
9.8 pts better
|
81.7%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.0% |
11.1%
5.1 pts better
|
12.0%
6 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.0% |
69.7%
18.3 pts better
|
79.7%
8.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.4% |
25.0%
4.6 pts better
|
23.9%
3.5 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-01 · Fire 2022-12-01
17 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2019-12-12 · Fire 2019-12-12
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-01-23
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-01-23
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-01-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-01-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-14
F · Potential for more than minimal harm
2022-12-01
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-01-23
E · Potential for more than minimal harm
2022-12-01
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-01-23
E · Potential for more than minimal harm
2022-12-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-01
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-01-23
F · Potential for more than minimal harm
2019-12-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2020-01-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-18
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-12-23
D · Potential for more than minimal harm
2025-08-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-01-23
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-23
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-23
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-23
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-02-24
B · Minimal harm
2025-01-23
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-02-24
B · Minimal harm
2025-01-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-24
D · Potential for more than minimal harm
2024-09-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-05-14
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-06-17
D · Potential for more than minimal harm
2023-11-29
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-11-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-08
E · Potential for more than minimal harm
2022-12-01
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-01-12
E · Potential for more than minimal harm
2022-12-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-01-12
E · Potential for more than minimal harm
2022-12-01
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-01-12
D · Potential for more than minimal harm
2022-12-01
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-01-12
D · Potential for more than minimal harm
2022-12-01
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-01-12
D · Potential for more than minimal harm
2022-12-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-01-12
D · Potential for more than minimal harm
2022-12-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-01-12
D · Potential for more than minimal harm
2022-12-01
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-01-12
D · Potential for more than minimal harm
2022-12-01
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-01-12
D · Potential for more than minimal harm
2022-12-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-01-12
D · Potential for more than minimal harm
2022-12-01
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-01-12
D · Potential for more than minimal harm
2022-12-01
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-01-12
D · Potential for more than minimal harm
2022-12-01
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-01-12
D · Potential for more than minimal harm
2022-12-01
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-01-12
C · Minimal harm
2022-12-01
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-01-12
G · Actual harm
2019-12-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2020-01-23
D · Potential for more than minimal harm
2019-12-12
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2020-01-23
B · Minimal harm
2019-12-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-01-23
Penalties and ownership
What sits behind the stars
Ownership
Ct-2 Operations Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Bak, Pinchos
Operational/Managerial Control · Individual
Bak, Pinchos
Corporate Officer · Individual
Ct-2 Opco Manager LLC
Operational/Managerial Control · Organization
Goldberger, Shlomo
Operational/Managerial Control · Individual
Gottlieb, Moshe
5% Or Greater Indirect Ownership Interest · Individual
Gottlieb, Moshe
Limited Partnership Interest · Individual
Gottlieb, Moshe
Operational/Managerial Control · Individual
Hennessey, John
Operational/Managerial Control · Individual
Jmh Family LLC
5% Or Greater Indirect Ownership Interest · Organization
Jmh Family LLC
Limited Partnership Interest · Organization
Jmh Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Jmh Family Trust
Limited Partnership Interest · Organization
Malt Family Trust
Limited Partnership Interest · Organization
Mls Family LLC
5% Or Greater Indirect Ownership Interest · Organization
Mls Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Mls Family Trust
Limited Partnership Interest · Organization
Peglow, Susan
Operational/Managerial Control · Individual
Sgs 2010 Family Trust
Limited Partnership Interest · Organization
Sgs Family LLC
5% Or Greater Indirect Ownership Interest · Organization
Sgs Family LLC
Limited Partnership Interest · Organization
Sgs Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Sgs Family Trust
Limited Partnership Interest · Organization
Shaw, Lindsay
Operational/Managerial Control · Individual
Sonnenschein, Moshe
Operational/Managerial Control · Individual
Tyh 2017 Trust
Limited Partnership Interest · Organization
Nearby options
Other facilities in reach
#1
Avalon Health Care Center At Stoneridge
Mystic, CT
5-star overall rating with 5-star inspections with $8,018 in total fines with 5 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#2
Mystic Healthcare & Rehabilitation Center, LLC
Mystic, CT
1-star overall rating with 2-star inspections with abuse icon flag with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Apple Rehab Mystic
Mystic, CT
3-star overall rating with 3-star inspections with $16,588 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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