Inspection Reports for Pendleton Rehabilitation and Nursing Center
44 Maritime Dr, Mystic, CT 06355, United States, CT, 06355
Back to Facility ProfileInspection Report Summary
The most recent inspection on January 9, 2026, found no new deficiencies and confirmed that a previously cited violation was corrected as of December 23, 2025. Earlier inspections showed a pattern of identified deficiencies related to regulatory compliance under 42 CFR Part 483, but these issues were addressed and corrected in a timely manner. Prior reports noted violations that were resolved through plans of correction, with no fines, immediate jeopardy findings, or license actions listed in the available reports. Complaint investigations mentioned in a January 23, 2025 inspection did not include substantiation status, and no enforcement actions were noted. The facility’s record indicates improvement over time, with recent audits confirming compliance and resolution of earlier deficiencies.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
1.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
75% better than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
92% occupied
Based on a January 2026 inspection.
Census over time
Inspection Report
Monitoring
Census: 110
Capacity: 120
Deficiencies: 1
Jan 9, 2026
Visit Reason
A desk audit was completed to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities following a previous deficiency cited on 2025-11-18.
Findings
One previously cited violation was identified as corrected as of 2025-12-23. No new non-compliance was found and the facility is in compliance with all regulations.
Deficiencies (1)
| Description |
|---|
| Previous deficiency cited on 2025-11-18 corrected as of 2025-12-23 |
Report Facts
Licensed Bed Capacity: 120
Census: 110
Inspection Report
Monitoring
Census: 110
Capacity: 120
Deficiencies: 1
Jan 9, 2026
Visit Reason
A desk audit was completed to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities following a previous deficiency cited on 2025-11-18.
Findings
One previously cited violation was identified as corrected as of 2025-12-23. No new non-compliance was found and the facility is in compliance with all regulations.
Deficiencies (1)
| Description |
|---|
| Previous deficiency cited on 2025-11-18 related to 42 CFR Part 483 requirements for Long Term Care Facilities |
Report Facts
Licensed Bed Capacity: 120
Census: 110
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Siobhan O'Neill | Survey Team Leader | Named as survey team leader conducting the inspection |
| Karen Gworek | Supervisor | Named as supervising nurse consultant/health program supervisor |
| Susan Peglow | Administrator | Personnel contacted during inspection |
Inspection Report
Monitoring
Census: 115
Capacity: 120
Deficiencies: 1
Sep 15, 2025
Visit Reason
A desk audit was conducted to monitor compliance with a previously cited deficiency related to 42 CFR Part 483 requirements for Long Term Care Facilities.
Findings
The audit found that one previously cited violation was corrected as of 2025-09-08, with no new non-compliance identified. The facility is in compliance with all regulations.
Deficiencies (1)
| Description |
|---|
| Previously cited deficiency related to 42 CFR Part 483 requirements |
Report Facts
Licensed Bed Capacity: 120
Census: 115
Deficiencies corrected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Siobhan O'Neill | Survey Team Leader | Lead surveyor conducting the inspection |
| Maureen Golas Markure | Supervisor, SNC | Supervising nurse consultant overseeing the inspection |
Inspection Report
Renewal
Census: 118
Capacity: 120
Deficiencies: 0
Jan 23, 2025
Visit Reason
The inspection visit was conducted as a licensing inspection including renewal and complaint investigation purposes.
Findings
The report indicates that violations of the General Statutes of Connecticut and/or regulations were identified during the inspection, with attached violation letters referenced. No narrative report or additional information is attached in this document.
Complaint Details
Complaint investigation referenced with complaint numbers 415167 and CT#35614; substantiation status not stated.
Report Facts
Licensed Bed Capacity: 120
Census: 118
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Peglow | Personnel contacted during inspection | |
| Lindsay Shaw | Personnel contacted during inspection |
Inspection Report
Monitoring
Census: 116
Capacity: 120
Deficiencies: 1
Jun 24, 2024
Visit Reason
A desk audit was conducted on 6/24/24 to review the implementation of the Plan of Correction for a prior violation letter dated 05/20/24.
Findings
Violations #1 were identified and corrected as of 6/17/24. The Administrator, Susan Peglow, confirmed via telephone on 6/24/24 that all violations were corrected.
Deficiencies (1)
| Description |
|---|
| Violation #1 identified and corrected |
Report Facts
Licensed Bed Capacity: 120
Census: 116
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Peglow | Administrator | Notified via telephone that all violations were corrected |
Inspection Report
Follow-Up
Census: 102
Capacity: 120
Deficiencies: 3
Apr 4, 2023
Visit Reason
A desk audit was conducted to review the plan of correction for a prior violation letter dated 2/28/23.
Findings
All three violations identified in the prior inspection were corrected as of 3/3/23, and the administrator was notified on 4/4/23 that all violations were corrected.
Deficiencies (3)
| Description |
|---|
| Violation #1 |
| Violation #2 |
| Violation #3 |
Report Facts
Licensed Bed Capacity: 120
Census: 102
Violations corrected: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judy Birtwistle | SNC | Report submitted by and signature on inspection report |
Inspection Report
Original Licensing
Deficiencies: 0
Sep 11, 2022
Visit Reason
This document is a Pre-Licensure Consent Order for Pendleton SNF Operations LLC seeking an initial license to operate a Chronic and Convalescent Nursing Home in Connecticut.
Findings
The document outlines the terms and conditions for the issuance of the nursing home license, including requirements for an Independent Nurse Consultant (INC), infection preventionist, staffing ratios, quality assurance, emergency preparedness, and other regulatory compliance measures.
Report Facts
Duration of Order: 1
INC consulting hours: 8
Infection preventionist hours: 32
Nurse staffing ratios: 30
Nurse aide staffing ratios: 12
Nurse aide staffing ratios: 20
Retention period for records: 5
Quality Assurance Committee meeting frequency: 30
Water management program report timeframe: 14
Plan of correction implementation timeframe: 14
Payment terms for vendors: 90
Fine amount: 1000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kim Hriceniak | Public Health Services Manager | Acting on behalf of the Department in executing the Pre-Licensure Consent Order |
| Moshe Gottlieb | Member | Member of Pendleton SNF Operations LLC, signing the Consent Order |
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