Pendleton Rehabilitation and Nursing Center

Name: Pendleton Rehabilitation and Nursing Center
Address: 44 MARITIME DRIVE, Mystic, CT, 06355, US
Telephone: 8605721700

44 Maritime Drive, Mystic, CT 06355 · Southeastern Ct County · 120 certified beds · avg 116 residents/day · certified since Feb 20, 1991

Part of chain: ATLAS HEALTHCARE (29 facilities, chain avg rating 3.6★)

4/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.46

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★★☆4/5 · CMS overall rating: 5/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Dec 12, 2019 · F-0689

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Jan 23, 2020 (Deficient, Provider has date of correction)

All citations in the current public record (32)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Nov 18, 2025	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Aug 6, 2025	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Jan 23, 2025	D · Potential for harm, one-off	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Jan 23, 2025	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Jan 23, 2025	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Jan 23, 2025	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Jan 23, 2025	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jan 23, 2025	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Jan 23, 2025	B · Minimal risk, repeated	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Jan 23, 2025	B · Minimal risk, repeated	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Sep 18, 2024	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
May 14, 2024	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Nov 29, 2023	D · Potential for harm, one-off	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Nov 29, 2023	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Dec 1, 2022	E · Potential for harm, repeated	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Dec 1, 2022	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Dec 1, 2022	E · Potential for harm, repeated	The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Dec 1, 2022	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Dec 1, 2022	D · Potential for harm, one-off	The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time.
Dec 1, 2022	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Dec 1, 2022	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Dec 1, 2022	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Dec 1, 2022	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Dec 1, 2022	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Dec 1, 2022	D · Potential for harm, one-off	The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Dec 1, 2022	D · Potential for harm, one-off	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Dec 1, 2022	D · Potential for harm, one-off	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Dec 1, 2022	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Dec 1, 2022	C · Minimal risk, facility-wide	The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day.
Dec 12, 2019	▲ G · Actual harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Dec 12, 2019	D · Potential for harm, one-off	The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Dec 12, 2019	B · Minimal risk, repeated	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (15 → 8).

Year	Citations	Serious (G–L)	Worst severity that year
2019	3	1	G ▲
2022	15	0	E
2023	2	0	D
2024	2	0	D
2025	10	0	D

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Connecticut avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	3.46	3.80	3.95	bottom 37% in Connecticut; bottom 35% in the U.S.
Registered Nurse hours	0.67	0.70	0.69	top 40% in Connecticut; top 40% in the U.S.
Weekend total nurse staffing	3.09	3.43	3.50	bottom 31% in Connecticut; bottom 36% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.35	0.46	0.48	bottom 42% in Connecticut; bottom 43% in the U.S.
Total nursing staff turnover (%)	33.7	37.4	45.8	top 37% in Connecticut; top 21% in the U.S.
RN turnover (%)	12.5	38.6	42.9	top 8% in Connecticut; top 6% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.75, RN 0.72, weekend 3.35. Staffing rating: 3/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 4/5 · short-stay residents: 5/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Ct-2 Operations Holdings LLC	Organization	5% or Greater Direct Ownership Interest	100%	09/01/2022
Gottlieb, Moshe	Individual	Indirect Ownership Interest	NOT APPLICABLE	09/01/2022
JMH Family LLC	Organization	5% or Greater Indirect Ownership Interest	—	09/01/2022
JMH Family Trust	Organization	5% or Greater Indirect Ownership Interest	—	09/01/2022
MLS Family LLC	Organization	5% or Greater Indirect Ownership Interest	—	09/01/2022
MLS Family Trust	Organization	5% or Greater Indirect Ownership Interest	—	09/01/2022
SGS Family LLC	Organization	5% or Greater Indirect Ownership Interest	—	09/01/2022
SGS Family Trust	Organization	5% or Greater Indirect Ownership Interest	—	09/01/2022
44 Maritime Drive Realty LLC	Organization	ADP of the SNF	NOT APPLICABLE	07/03/2025
Bak, Pinchos	Individual	Corporate Officer	NOT APPLICABLE	09/01/2022
Bak, Pinchos	Individual	Operational/Managerial Control	NOT APPLICABLE	09/01/2022
Bak, Pinchos	Individual	ADP of the SNF	NOT APPLICABLE	09/01/2022
Ct-2 Opco Manager LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	09/01/2022
Ct-2 Opco Manager LLC	Organization	ADP of the SNF	NOT APPLICABLE	07/04/2025
Goldberger, Shlomo	Individual	Operational/Managerial Control	NOT APPLICABLE	09/01/2022
Goldberger, Shlomo	Individual	ADP of the SNF	NOT APPLICABLE	09/01/2022
Gottlieb, Moshe	Individual	Operational/Managerial Control	NOT APPLICABLE	09/01/2022
Gottlieb, Moshe	Individual	Limited Partnership Interest	NOT APPLICABLE	09/01/2022
Gottlieb, Moshe	Individual	ADP of the SNF	NOT APPLICABLE	09/01/2022
Hennessey, John	Individual	Operational/Managerial Control	NOT APPLICABLE	09/01/2022

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"How do you keep residents' medical records accurate, complete, and secure?"
"Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
"If my family member falls or their condition changes, exactly when and how will I be notified?"
"Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
"How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"What percentage of your residents and staff are vaccinated against flu and pneumonia, and how do you offer the vaccines?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Avalon Health Care Center at Stoneridge	0.3 mi	Mystic, CT	★★★★★	5/5
Mystic Healthcare & Rehabilitation Center, LLC	1.3 mi	Mystic, CT	★☆☆☆☆	1/5	abuse
Apple Rehab Mystic	1.4 mi	Mystic, CT	★★☆☆☆	3/5
Complete Care at Groton Regency	5.0 mi	Groton, CT	★★★★★	4/5
Royal of Westerly Nursing Center	6.4 mi	Westerly, RI	★★★★☆	4/5
Westerly Health Center	6.8 mi	Westerly, RI	★★★☆☆	3/5
Fairview	6.8 mi	Groton, CT	★★★★☆	4/5
Beechwood Health & Rehabilitation Center	8.0 mi	New London, CT	★★★★☆	4/5
Harbor Village North Health and Rehabilitation Cen	8.3 mi	New London, CT	★☆☆☆☆	1/5	abuse
Apple Rehab Clipper	8.9 mi	Westerly, RI	★★★★☆	4/5

Compare this facility with the 3 closest →

All facilities in Mystic →

Facility data as of CMS processing date 2026-08-01. CCN 075341.

The Care File

Visit checklist — Pendleton Rehabilitation and Nursing Center

44 Maritime Drive, Mystic, CT 06355 · 8605721700

Health inspection rating 4/5 · CMS overall 5/5· Fines (3y): $0

Most serious findings on record:

▲ Dec 12, 2019 (F-0689, Actual harm, one-off): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Questions for the administrator:

☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "How do you keep residents' medical records accurate, complete, and secure?"
☐ "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
☐ "If my family member falls or their condition changes, exactly when and how will I be notified?"
☐ "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
☐ "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "What percentage of your residents and staff are vaccinated against flu and pneumonia, and how do you offer the vaccines?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 075341 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)