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
Chain footprint
28 facilities
Chain averages 4 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.65
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.84 · national 0.87
Aide hours / resident day
2.18
Nurse aide staffing · state 2.28 · national 2.35
Total nurse hours
3.72
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.54 · national 1.54
Weekend hours
3.42
Weekend nurse staffing · state 3.41 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
3.59
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
32%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,631
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.66
Composite VBP score used to determine payment impact.
Payment multiplier
1.0024
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.75
Baseline 19.68% · Performance 17.38% · Measure score 8.75 · Achievement 8.75 · Improvement 8.19
Healthcare-associated infections
4.03
Baseline 7.95% · Performance 6.63% · Measure score 4.03 · Achievement 4.03 · Improvement 3.96
Total nurse turnover
4.80
Baseline 52.13% · Performance 44.07% · Measure score 4.80 · Achievement 4.80 · Improvement 2.45
Adjusted total nurse staffing
1.88
Baseline 4.12 hours · Performance 3.61 hours · Measure score 1.88 · Achievement 1.88 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.58% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 183 · Observed rate 15.3% · Lower 95% interval 8.58% |
| Discharge to community | 56.11% |
50.57%
5.5 pts better
|
No Different than the National Rate · Eligible stays 194 · Observed rate 46.39% · Lower 95% interval 47.79% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.31% |
95.27%
4 pts better
|
Numerator 143 · Denominator 144 |
| Falls with major injury | 0.69% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 144 |
| Discharge self-care score | 55.21% |
53.69%
1.5 pts better
|
Numerator 53 · Denominator 96 |
| Discharge mobility score | 51.04% |
50.94%
0.1 pts better
|
Numerator 49 · Denominator 96 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 144 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.63% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 133 · Observed rate 8.27% · Lower 95% interval 4.14% |
| Staff COVID-19 vaccination coverage | 5.29% |
8.2%
2.9 pts worse
|
Numerator 10 · Denominator 189 |
| Staff flu vaccination coverage | 28.63% |
42%
13.4 pts worse
|
Numerator 71 · Denominator 248 |
| Discharge function score | 55.21% |
56.45%
1.2 pts worse
|
Numerator 53 · Denominator 96 |
| Transfer of health information to provider | 94.87% |
95.95%
1.1 pts worse
|
Numerator 37 · Denominator 39 |
| Transfer of health information to patient | 91.43% |
96.28%
4.8 pts worse
|
Numerator 64 · Denominator 70 |
| Resident COVID-19 vaccinations up to date | 28.89% |
25.2%
3.7 pts better
|
Numerator 26 · Denominator 90 |
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 · Adjusted 1.6 · Observed 2.5 · Expected 3.0 · Used in QM five-star |
| 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 · Adjusted 1.8 · Observed 2.1 · Expected 2.0 · Used in QM five-star |
| 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 · Q1 91.0% · Q2 94.8% · Q3 100.0% · Q4 100.0% · 4Q avg 96.5% |
| 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 · 4Q avg 100.0% |
| 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 · Q1 4.0% · Q2 4.1% · Q3 5.9% · Q4 5.1% · 4Q avg 4.8% · Used in QM five-star |
| 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 · Q1 2.4% · Q2 1.1% · Q3 3.5% · Q4 27.7% · 4Q avg 8.5% |
| 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 · Q1 5.8% · Q2 3.3% · Q3 6.4% · Q4 9.1% · 4Q avg 6.1% |
| 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 · Q1 19.6% · Q2 22.6% · Q3 23.7% · Q4 21.5% · 4Q avg 21.9% |
| 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 · Q1 12.1% · Q2 12.7% · Q3 12.5% · Q4 22.6% · 4Q avg 14.8% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · Q1 16.4% · Q2 8.4% · Q3 6.4% · Q4 12.5% · 4Q avg 10.9% · Used in QM five-star |
| 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 · Q1 12.6% · Q2 10.3% · Q3 6.7% · Q4 12.6% · 4Q avg 10.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · Q1 1.1% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| 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 · Q1 20.8% · Q2 21.6% · Q3 35.4% · Q4 33.7% · 4Q avg 28.1% |
| 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 · Q1 3.3% · Q2 1.3% · Q3 4.3% · Q4 3.2% · 4Q avg 3.0% · Used in QM five-star |
| 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 · Q1 74.8% · Q2 81.7% · Q3 95.4% · Q4 70.4% · 4Q avg 80.3% |
| 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 · Adjusted 6.0% · Observed 5.8% · Expected 10.8% · Used in QM five-star |
| 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 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| 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 · 4Q avg 88.0% |
| 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 · Adjusted 20.4% · Observed 20.6% · Expected 24.2% · Used in QM five-star |
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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