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Deficiency Records for Pendleton Manor
A list of the most recent deficiencies for Pendleton Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Pendleton Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-04-30 | 2024-06-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-04-30 | 2024-06-24 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-04-30 | 2024-06-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-04-30 | 2024-06-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-04-30 | 2024-06-24 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-04-30 | 2024-06-24 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-04-30 | 2024-06-24 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-05-01 | 2024-05-30 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-05-01 | 2024-05-30 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-05-01 | 2024-05-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-01 | 2024-05-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-01 | 2024-05-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-05-01 | 2024-05-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-01 | 2024-05-30 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-08-30 | 2022-10-17 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-08-30 | 2022-10-17 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-08-30 | 2022-10-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-30 | 2022-10-17 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-08-30 | 2022-10-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-08-30 | 2022-10-17 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-08-30 | 2022-10-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-30 | 2022-10-14 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-08-30 | 2022-10-14 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-08-30 | 2022-10-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-30 | 2022-10-14 | N |
| Respond appropriately to all alleged violations. | Health | 2022-08-30 | 2022-10-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-30 | 2022-10-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-30 | 2022-10-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-08-30 | 2022-10-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-30 | 2021-09-13 | Y |
| Meet other general requirements that are deficient. | Fire Safety | 2021-05-11 | 2021-07-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-11 | 2021-07-13 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-11 | 2021-06-02 | N |
| 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. | Health | 2021-05-11 | 2021-06-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-11 | 2021-06-02 | N |
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