Pendleton Manor

Inspectors wroteBased on record review, observation and staff interview, the facility failed to ensure the resident's environment maintained or enhanced dignity and respect during the dining experience. The failed practice had the potential to affect a limited number of residents. Facility Census: 84.

Inspectors wroteBased upon observations, staff interviews and record reviews, the facility failed to ensure that it remained free from accident hazards in resident accessible areas. There were multiple areas with accident hazards or hazardous products that could be reached by residents while under the care and control of the facility. This was discovered during the normal Long Term Survey Process and has the ability to affect more than a limited number of residents. Census 84.a) At 9:50 AM, an observation of the 500 hall nourishment room and resident dining area revealed that residents had access to the mini-kitchen. Under the sink, a can of Scrubbing Bubbles and a gallon of white vinegar were found. Additionally, a manual can opener with sharp edges was left on the stovetop. [...]

Inspectors wroteBased on observation and staff interviews the facility failed to provide food at a safe appetizing temperature. This failed practice had the potential to affect all residents in the facility. Resident identifiers #'s 79 and 38 Facility census: 87 a) During facility walkthrough and resident interviews, Resident #79 stated that food was a sore point; the food is terrible. Whoever cooks it .ruins it. and it has been cold. In an interview with Resident # 38 on 02/26.26, at 2:15 PM, she stated The food is ok but sometimes its too cold when it gets here. During an observation on 02/27/26 at 1:15 PM of the 400 hall meals being passed without a heated cart and only 2 staff members delivering all trays to residents on that hall. The dietary manager took the temperature of the food, at time of service. The food temperatures were as follows: Lasagna 57 degrees Fahrenheit. [...]

Inspectors wroteBased on observation, interview and policy review the facility failed to properly store food in accordance with professional standards. This is true for the facility kitchen and nourishment pantries. This had the potential to affect all residents in the facility. Facility census: [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure an infection prevention and control program per professional standards was maintained and followed. This failed practice had the potential to affect more than a limited number of residents. Resident #'s 17 and 58 Facility Census: 84. Resident #17 During an interview with Resident #17 on 02/25/25 at 3:50 PM, observation revealed the wheelchair she was sitting in, had cracks and tears, exposing padding on both armrests. Resident #38 During resident observation and interviews on 02/25/26 4:08 PM, it was observed Resident #38's wheelchair had a tear with exposed padding on the back rest . In an interview with the infection preventionist on 02/25/2026 at 2:30 PM, she acknowledged the two (2) wheelchairs for Resident #'s 38 and #17 had exposed padding causing an infection control issue. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to notify the physician of a change in condition for a resident's admission to hospice services. Resident Identifier: #47. Facility Census: 84.

Inspectors wroteBased on record review and staff interview, the facility failed to send a copy of the Notice of Transfer/Discharge form to the Long-Term Care Ombudsman when a resident was discharge to an acute care setting. Resident Identifier: #7. Facility Census: 84.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure Resident #7 received medications as ordered by the physician. Insulin aspart [NovoLog] (a medication used to control blood sugar in people with diabetes mellitus) was not administered and documented in accordance with professional standards of practice. This affected one (1) of five (5) residents reviewed for unnecessary medications during the long-term care survey process. Resident identifier: #7. Facility census: 84.

Inspectors wroteBased on observation, medical record review, and staff interview the facility failed to establish and maintain an infection prevention program to help prevent the development and transmission of communicable diseases and infections including Covid-19 in regard to, precaution signage on the entrance, positive Covid-19 precaution signage on resident doors, water management and expired Sani Wipes. This has to potential to affect all residents that reside in the facility. Identifier: room [ROOM NUMBER]. Facility Census: 77. Findings Include: a) Precaution Signage on Entrance Door An observation on [DATE] at 12:00PM of the facility's front entrance revealed no precautionary signage located on the door informing visitors of Covid-19 in the building. During an interview on [DATE] at 4:02 PM, the Director of Nursing verified there was no precautionary signage for visitors on the front entrance. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for residents with newly evident and possible serious mental disorders. This was true for three (3) of six (6) residents reviewed for PASARRs during the survey process. Resident Identifier: #11, #28, and #49. Facility census: 77.

Inspectors wroteBased on observation and staff interview, the facility failed to provide an environment which was free from accident hazards over which they had control. The facility did not identify a toaster that was plugged in and operable in the Kitchenette on the 500 Hall as a hazard. This had the potential to affect every resident residing on the 500 hall. Resident identifiers: #64, #7, #30, #56, #26, #3, #6, #39, #19, #65, #42, #8, #28. Facility census:

Inspectors wroteBased on observation and staff interview, the facility failed to secure and keep confidential residents personal and medical information. A restorative note was visible on a rolling workstation desk in the 400 hallway for Resident #47. The form identified Parkinson's as a diagnosis for the resident. This was a random opportunity for discovery and was true for only Resident #47. Resident #47. Facility census: 77.

Inspectors wroteBased on record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for residents admitted to the facility diagnosed with possible serious mental disorders. This was true for one (1) of six (6) residents reviewed for PASARRs during the survey process. Resident Identifier: 23 . Facility census: 77.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to collaborate with Hospices services. This was true for one (1) of one (1) residents reviewed for hospice services during the long term care survey. Resident Identifier: Resident # 63. Facility Census: 77. Findings Include: a) Resident #63 A medical record review revealed Resident #63 was receiving Hospice Services starting on 03/27/24. A continued record review of physician's orders showed an order for: -- Admit to Hospice, DX dementia. Review of Resident # 63's Hospice documentation notebook showed it did not contain an active care plan or collaborating documentation from Hospice Services. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure complete and accurate medical records. Physician Orders for Scope of Treatment (POST) forms were incomplete and/or inaccurate for two (2) of three (3) records reviewed for accurate POST forms. Resident identifiers: #176 and #9. Facility census: 77.

Inspectors wroteBased on Resident council meeting, record review and staff interview, the facility failed to resolve a group grievance concerning call lights in a timely manner. This was discovered during the resident council meeting and had a potential to affect more than a limited number of residents. Facility census 64.

Inspectors wroteBased on record review, policy review and staff interview the facility failed to implement their abuse and neglect policy in regard to reporting allegations of abuse and neglect for Resident #52 and #36. In addition the facility failed to thoroughly investigate all allegations of abuse and neglect for Resident #51, #62, #37, and #49. This was a random opportunity for discovery found during the long term care survey process. Facility Census: 64. Findings Included: a) Allegations against Former Nurse Aide (NA) #148 involving Resident #51, #62, and #37. A review of the facility's reportable incidents found a reportable incident dated 07/21/22. The allegation contained on this report read as follows: Allegedly (First and last Name of Former Nurse Aide #148) was making sexually inappropriate comments to the male residents on the 200 hall. [...]

Inspectors wroteBased on record review and staff interview the facility failed to thoroughly investigate all allegations of abuse and or neglect. This was a random opportunity for discovery and was found to be true for Resident #51, #62, #37 and #49. Resident Identifier: #51, #62, #37, and #49. Facility Census: 64. Findings Included: a) Allegations against Former Nurse Aide (NA) #148 involving Resident #51, #62, and #37. A review of the facility's reportable incidents found a reportable incident dated 07/21/22. The allegation contained on this report read as follows: Allegedly (First and last Name of Former Nurse Aide #148) was making sexually inappropriate comments to the male residents on the 200 hall. A review of the investigation found the following statements: -- Statement from Nurse Aide #75. Typed as written: [...]

Inspectors wroteBased on Resident interview, staff interview, and record review the facility failed to ensure all residents were able to have their choices honored in regard to bathing and bedtime. This was a random opportunity for discovery discovered during the resident council meeting held on 08/30/22. Resident identifier: #35. Facility census 64.

Inspectors wroteBased on medical record review, observation, resident, and staff interview; the facility failed to notify Resident #65's physician and family of resident's traumatic laceration on the resident's left lower leg. This was true for one (1) of one (1) residents reviewed for the care area of notification of change. Resident identifier: #65. Facility census: 64.

Inspectors wroteBased on record review and staff interview the facility failed to report all allegations of abuse and neglect to appropriate state agencies as required. This was found to be true for Resident #52 and #36 and was a random opportunity for discovery. Resident Identifiers: #52 and #36. Facility Census: 64.

Inspectors wroteBased on record review and staff interview, the facility failed to notify the State Ombudsman of transfers to an acute care facility for Resident #36 and #58. This was true for two (2) of two (2) residents reviewed under the care area of hospitalizations during the long-term survey. Resident Identifiers: #36 and #58. Facility Census: 64. Findings Included: a) Resident #36 On 08/29/22 at 11:25 AM, a record review was completed for Resident #36. This review found Resident #36 was transferred to an acute care facility after a fall on 07/14/22. The fall resulted in a major injury of a closed torus fracture of the distal end of the left femur. On 08/30/22 at 1:30 PM, Registered Nurse Manager (RN) #121 confirmed the State Ombudsman was not notified of the transfer. b) Resident #58 On 08/30/22 at 11:00 AM, a record review was completed for Resident #58. [...]

Inspectors wroteBased on medical record review, observation, resident, and staff interview; the facility failed to follow Resident #5's physician order for daily weights and notification of the physcian. This was a random opputunity for discovery. Resident identifiers: #5. Facility census: 64.

Inspectors wroteBased on resident council concerns and staff interview, the facility failed to ensure the food was palatable, attractive, and at a safe and appetizing temperature for all residents. This was a random opportunity for discovery. Resident Identifier: #14. Facility census: 64.