Deficiency Records for Pendleton Manor
Updated as of April 01, 2023
This is not the most recent data for Pendleton Manor. For the most recent information, click here.
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 | 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 |
| 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 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-08 | 2020-02-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-01-08 | 2020-02-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-01-08 | 2020-02-13 | 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 | 2020-01-08 | 2020-01-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-01-08 | 2020-01-13 | N |
