Inspection Reports for
Pendleton Rehabilitation and Nursing Center
44 Maritime Dr, Mystic, CT 06355, United States, CT, 06355
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% worse than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
92% occupied
Based on a January 2026 inspection.
Occupancy rate over time
Inspection Report
Monitoring
Census: 110
Capacity: 120
Deficiencies: 1
Date: 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)
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
Date: 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)
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
Complaint Investigation
Deficiencies: 1
Date: Nov 18, 2025
Visit Reason
The inspection was conducted in response to allegations of physical and verbal abuse reported by residents against nurse aides at Pendleton Rehabilitation and Nursing Center.
Complaint Details
The investigation was triggered by complaints of physical abuse to Resident #1 and verbal and physical abuse to Resident #2. Both allegations were substantiated with investigations initiated, nurse aides suspended, and notifications made to family, provider, and police. Documentation deficiencies were noted in nursing assessments and notes.
Findings
The facility failed to ensure nursing assessments and documentation were completed and recorded in the clinical records following allegations of abuse for two residents. Investigations were initiated, nurse aides were suspended, but required nursing notes and assessments were missing or backdated.
Deficiencies (1)
F 0842: The facility failed to ensure a nursing assessment was completed and documented in the clinical record at the time an allegation of abuse was reported for two residents. Documentation was incomplete, untimely, and backdated in some cases.
Report Facts
Residents affected: 2
Bruise size: 1.5
Bruise size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Assessed Resident #1 following abuse allegation but failed to document assessment or allegation in clinical record |
| Director of Nursing | Director of Nursing | Created late SBAR entry and identified documentation deficiencies |
| Nursing Supervisor | Nursing Supervisor | Reported Resident #1's family member's abuse allegation and acknowledged failure to document assessment |
Inspection Report
Monitoring
Census: 115
Capacity: 120
Deficiencies: 1
Date: 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)
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
Deficiencies: 1
Date: Aug 6, 2025
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality in response to incidents involving Resident #1 who experienced multiple unwitnessed falls.
Findings
The facility failed to complete neurological checks as required by facility policy after multiple unwitnessed falls of Resident #1 on 7/5/2025. Neurological assessments were not consistently performed every half hour for four times after the 4:10 PM fall, leading to delayed recognition of the resident's decline and subsequent hospital admission.
Deficiencies (1)
F 0658: The facility failed to ensure neurological checks were completed every half hour times four after an unwitnessed fall on 7/5/2025 as required by facility policy. Neurological assessments after the 4:10 PM fall were incomplete and not performed at the required intervals, contributing to delayed detection of Resident #1's acute condition.
Report Facts
Falls: 3
Neurological checks: 4
Abrasions: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Initiated neurological record after the 1:00 PM fall and responded to the 4:10 PM fall. | |
| LPN #2 | Responsible for neurological checks during 3:00 PM to 11:00 PM shift on 7/5/2025; did not recall initiating new neurological checks after the 4:10 PM fall. | |
| RN #1 | Assessed Resident #1 after each fall and expected staff to initiate neurological checks per policy. | |
| RN #2 | Assessed Resident #1 after each fall and expected neurological checks to be initiated as directed. | |
| DON | Director of Nursing | Stated expectation that staff follow neurological check monitoring frequency after each fall; no physician order was present to direct assessments. |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Jan 23, 2025
Visit Reason
Annual inspection survey conducted to assess compliance with healthcare regulations at Pendleton Rehabilitation and Nursing Center.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of resident condition changes, improper medication administration and storage, inaccurate resident assessments, incomplete care plans, failure to provide scheduled showers, and failure to administer requested pneumococcal vaccination.
Deficiencies (8)
F 0580: The facility failed to notify the physician when Resident #88 experienced symptoms of pain and swelling in the left hand.
F 0584: The facility failed to ensure nebulizer equipment was stored, labeled properly, and discarded when not in use for Resident #12.
F 0641: The facility failed to ensure four Minimum Data Set assessments were accurately coded for dialysis for Resident #67.
F 0657: The facility failed to ensure the care plan addressed monitoring of possible side effects and emergent care for anticoagulant medication for Resident #88.
F 0658: The facility failed to ensure medications were administered according to acceptable standards of practice for Residents #22 and #101, including improper bedside medication storage and lack of physician orders for self-administration.
F 0677: The facility failed to provide showers as scheduled for Resident #44, with only two showers provided in three months.
F 0684: The facility failed to ensure Resident #22 received prescribed respiratory medications as ordered, with discrepancies in medication supply and administration.
F 0883: The facility failed to ensure Resident #18 received the requested pneumococcal vaccine upon admission.
Report Facts
Medication doses administered: 196
Medication doses dispensed: 120
Medication doses administered: 100
Medication doses dispensed: 120
Showers provided: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #5 | Registered Nurse | Named in failure to notify physician of Resident #88's condition |
| DNS | Director of Nursing Services | Interviewed regarding notification policies and care plan requirements |
| RN #3 | MDS Coordinator | Interviewed regarding inaccurate MDS assessments for Resident #67 |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding nebulizer equipment and medication administration |
| RN #4 | Unit Manager | Interviewed regarding medication storage and administration for Resident #22 |
| LPN #3 | Charge Nurse | Interviewed regarding medication administration and MAR signing for Resident #22 |
| RN #2 | Infection Preventionist Nurse | Interviewed regarding pneumococcal vaccination process for Resident #18 |
| MD #1 | Primary Physician | Interviewed regarding pneumococcal vaccine order for Resident #18 |
| Pharmacy Technician | Interviewed regarding medication dispensing records for Resident #22 |
Inspection Report
Renewal
Census: 118
Capacity: 120
Deficiencies: 0
Date: Jan 23, 2025
Visit Reason
The inspection visit was conducted as a licensing inspection including renewal and complaint investigation purposes.
Complaint Details
Complaint investigation referenced with complaint numbers 415167 and CT#35614; substantiation status not stated.
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.
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
Annual Inspection
Deficiencies: 1
Date: Jan 23, 2025
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with care standards, specifically reviewing activities of daily living (ADL) care for residents.
Findings
The facility failed to ensure that scheduled showers were provided to Resident #44 as planned, with documentation showing only two showers in three months despite a twice-weekly schedule. The documentation also lacked reasons for missed showers, and staff interviews revealed inconsistent understanding and recording of shower provision.
Deficiencies (1)
F 0677: The facility failed to provide scheduled showers to Resident #44, who required assistance with bathing. Documentation showed the resident received only two showers in three months without explanation for missed showers.
Report Facts
Scheduled showers missed: 22
Inspection Report
Deficiencies: 1
Date: Sep 18, 2024
Visit Reason
The inspection was conducted to investigate medication administration practices following a medication dosing error involving Resident #1 at Pendleton Rehabilitation and Nursing Center.
Findings
The facility failed to follow the physician's order for proper medication dosing and failed to heed warnings on the Medication Administration Record, resulting in Resident #1 receiving incorrect doses of Relugolix multiple times. The error was due to confusion caused by a multi-step medication order still displaying an outdated dose on the MAR.
Deficiencies (1)
F 0684: The facility failed to provide appropriate treatment and care according to physician orders and resident preferences. Resident #1 was administered three tablets of 120mg Relugolix instead of the prescribed one tablet on multiple occasions due to a confusing multi-step medication order.
Report Facts
Medication administrations: 93
Medication tablets delivered: 120
Medication tablets remaining: 27
Medication tablets misadministered: 3
Medication shipments: 30
Medication shipments: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #2 | Unit manager interviewed regarding medication administration error | |
| Registered Nurse (RN) #1 | Investigated missing medication and identified dosing error | |
| Pharmacist | Provided information on medication shipments and delivery | |
| Director of Nursing (DON) | Explained confusion caused by multi-step medication order on MAR |
Inspection Report
Monitoring
Census: 116
Capacity: 120
Deficiencies: 1
Date: 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)
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
Complaint Investigation
Deficiencies: 1
Date: May 14, 2024
Visit Reason
The inspection was conducted following a complaint alleging staff to resident abuse involving Resident #1, triggered by a family member's observation of rough handling on a camera monitor.
Complaint Details
The complaint was an allegation of staff to resident abuse observed on a camera monitor. The allegation was not substantiated, but the staff member failed to treat the resident with dignity and respect.
Findings
The facility failed to ensure care was provided with dignity and respect to Resident #1. Although the abuse allegation was not substantiated, the staff member (LPN #1) used a loud and degrading tone and left the resident in an unsafe position, resulting in termination of employment.
Deficiencies (1)
F 0550: The facility failed to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. LPN #1 used a loud and degrading tone and left Resident #1 in an unsafe position without injury.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in abuse allegation and deficiency related to failure to treat Resident #1 with dignity and respect. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 29, 2023
Visit Reason
The inspection was conducted based on a complaint regarding the facility's failure to notify the physician and properly assess, monitor, and treat a resident's pressure ulcers and skin impairments.
Complaint Details
The investigation was triggered by a complaint regarding failure to notify the physician and properly manage pressure ulcers for Resident #1. The complaint was substantiated with findings of inadequate assessment, monitoring, treatment, and communication.
Findings
The facility failed to notify the physician of pressure injuries for Resident #1 and did not adequately assess, monitor, or treat the resident's pressure ulcers. Documentation and communication lapses were identified, including failure to follow outpatient wound clinic recommendations and incomplete notification of changes to the physician and family.
Deficiencies (2)
F 0580: The facility failed to notify the physician of pressure injuries for Resident #1, who developed pressure ulcers secondary to a cam boot. Documentation of wounds and treatment was incomplete.
F 0686: The facility failed to assess, monitor, and treat Resident #1's pressure ulcers properly, including failure to follow outpatient wound clinic treatment recommendations and notify the physician of changes.
Report Facts
Pressure injury measurements: 1.1
Pressure injury measurements: 0.9
Pressure injury measurements: 0.5
Pressure injury measurements: 0.3
Pressure injury measurements: 0.3
Pressure injury measurements: 0.2
Pressure injury measurements: 1.4
Pressure injury measurements: 2
Pressure injury measurements: 0.1
Pressure injury measurements: 4
Pressure injury measurements: 4.7
Pressure injury measurements: 0.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Completed skin checks and monitored Resident #1's skin integrity |
| RN #3 | Registered Nurse | Completed skin check on 7/16/23 and was one of Resident #1's primary nurses |
| RN #4 | Registered Nurse | Completed nursing progress notes and skin checks for Resident #1 |
| LPN #1 | Licensed Practical Nurse | Resident #1's nurse on 7/4/23 and conducted skin checks |
| LPN #3 | Licensed Practical Nurse | Resident #1's nurse on 7/12/23 and conducted foot checks |
| MD #1 | Contracted Wound Physician | Did not see Resident #1 during stay; responsible for wound rounds |
| OT #1 | Occupational Therapist | Reported family concerns about Resident #1's skin integrity |
| DNS | Director of Nursing Services | Interviewed regarding medical appointments and consultation reports |
| Wound RN | Wound Care Registered Nurse | Assessed Resident #1's wounds and reported on wound rounds |
| Outpatient Wound Physician | Physician | Assessed Resident #1 on 7/19/23 and identified deep tissue injury |
Inspection Report
Follow-Up
Census: 102
Capacity: 120
Deficiencies: 3
Date: 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)
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
Complaint Investigation
Deficiencies: 15
Date: Dec 1, 2022
Visit Reason
The inspection was conducted based on complaints and allegations related to resident care, dignity, privacy, neglect, medication management, staffing, and facility environment.
Complaint Details
The investigation was complaint-driven, focusing on allegations of neglect, failure to provide care, privacy violations, medication errors, and environmental sanitation issues. The complaint was substantiated with multiple deficiencies found.
Findings
The facility was found deficient in multiple areas including failure to provide dignified care and privacy, failure to follow care plans and transfer protocols, inadequate staffing and staff competency, failure to ensure comprehensive assessments and follow-up on hospital readmissions, medication management issues including unlabeled and improperly stored medications, failure to follow up on pharmacy recommendations, inadequate kitchen sanitation, and failure to maintain resident personal care items in a sanitary manner.
Deficiencies (15)
F 0550: The facility failed to provide care in a dignified manner and ensure privacy curtains were available for Resident #51 during care.
F 0561: The facility failed to provide a shower per Resident #42's preference, resulting in unmet resident choice.
F 0656: The facility failed to develop and implement a complete care plan including wheelchair lap belt use, two-person mechanical lift transfers, and discharge planning for Residents #21, #342, and #89.
F 0658: The facility failed to ensure registered nurses assessed residents upon return from acute care facilities for Residents #56 and #64.
F 0677: The facility failed to ensure Resident #342 was reproached after refusal of ADL care and that licensed staff were aware of the refusal.
F 0686: The facility failed to ensure dietary follow-up for Resident #60 with a newly developed pressure ulcer within facility practice.
F 0689: The facility failed to provide necessary assistive devices and follow transfer protocols for Resident #342, risking potential accidents.
F 0726: The facility failed to ensure sufficient staffing and nurse aide competency in reporting resident refusal of care for Resident #342.
F 0732: The facility failed to post accurate daily nurse staffing information reflecting actual licensed and unlicensed nursing staff hours worked.
F 0756: The facility failed to ensure pharmacy recommendations were reviewed and followed up by the physician for Resident #19's psychotropic medication management.
F 0758: The facility failed to ensure a psychiatric referral was made and a baseline AIMS assessment obtained for Resident #295 with newly prescribed antipsychotic medication.
F 0761: The facility failed to label and store medications properly, including unlabeled opened insulin pens and vials, unattended medication cards, and a medication refrigerator with improper temperature and door left ajar.
F 0812: The facility failed to maintain the kitchen in a clean and sanitary manner, including buildup on utensils, counters, and improper sanitizer solution concentration.
F 0842: The facility failed to ensure complete and accurate documentation of Resident #342's refusal of care and failed to report and follow up appropriately.
F 0921: The facility failed to maintain residents' personal care items in a safe, sanitary manner, including unlabeled bedpans, urinals, basins, and denture cups in multiple resident bathrooms.
Report Facts
Medication cards left unattended: 24
Sanitizing solution concentration: 0
Medication refrigerator temperature: 59
Medication refrigerator temperature: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #2 | Nurse Aide | Named in failure to provide care and refusal of care documentation for Resident #342 |
| RN #3 | Registered Nurse | Named in failure to report resident refusal of care for Resident #342 |
| RN #5 | Registered Nurse | Named in insulin labeling deficiency |
| Pharmacist #1 | Pharmacist | Named in insulin labeling deficiency |
| DNS | Director of Nursing Services | Named in multiple interviews regarding privacy, care plans, staffing, medication, and environment |
| FSD | Food Service Director | Named in kitchen sanitation deficiency |
| NA #7 | Nurse Aide | Named in failure to follow transfer protocol and refusal of care documentation |
| NA #4 | Nurse Aide | Named in failure to follow transfer protocol and refusal of care documentation |
| APRN #1 | Advanced Practice Registered Nurse | Named in psychiatric referral and medication management deficiency |
| RN #2 | Registered Nurse | Named in psychiatric referral and medication management deficiency |
Inspection Report
Original Licensing
Deficiencies: 0
Date: 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 |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Dec 12, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident rights, accurate assessments, and accident prevention.
Findings
The facility failed to provide advance directive information following hospital readmissions, inaccurately coded Minimum Data Set (MDS) assessments for multiple residents, and did not ensure adequate supervision during care, resulting in a resident fall with a fracture.
Deficiencies (3)
F 0578: The facility failed to provide advance directive information following hospital readmissions for Resident #51, resulting in inconsistent code status documentation and lack of resident notification.
F 0641: The facility failed to ensure accurate coding of Minimum Data Set assessments for four residents, including misclassification of mental health status, medication type, and hospice services.
F 0689: The facility failed to ensure two staff members were present during care for Resident #283, resulting in a fall and left distal femur fracture.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 1
Dates: 3
Medication doses administered: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Interviewed regarding Resident #51's code status and advance directive documentation |
| MDS Coordinator (RN #1) | Registered Nurse | Interviewed regarding inaccurate MDS coding for multiple residents |
| Pharmacist #1 | Pharmacist | Interviewed regarding medication classification for Resident #57 |
| DNS | Director of Nursing Services | Interviewed regarding circumstances of Resident #283's fall |
| NA #1 | Nurse Aide | Interviewed regarding care provided to Resident #283 during fall incident |
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