Inspection Reports for Pendleton Manor

The document is a plan of correction related to a prior investigation survey concluding on 2024-05-01, accepted in lieu of an onsite revisit.

Pendleton Manor is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with previously cited deficient practices corrected as evidenced by accepted plans of correction.

An unannounced Annual Survey was conducted at Pendleton Manor from 04/29/2024 to 05/01/2024 to assess compliance with federal regulations.

The facility was found deficient in multiple areas including failure to maintain resident privacy, incomplete and inaccurate medical records, failure to complete required PASARR assessments, environmental hazards, infection control deficiencies, and lack of collaboration with hospice services.

The inspection was the Standard Recertification Survey conducted on 04/29/2024 and 04/30/2024 to assess compliance with federal regulations for nursing facilities.

The facility was found deficient in multiple areas including fire safety (means of egress obstructions, hazardous area enclosures, smoke barriers, fire doors, HVAC fire and smoke dampers), electrical system maintenance and testing, smoking regulations, and emergency preparedness planning. The facility submitted plans of correction with completion dates mostly by June 2024.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with long term care facility regulations.

Pendleton Manor was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules. A review of plans of correction and credible evidence was accepted in lieu of an onsite revisit.

The inspection was conducted as a Standard Recertification Survey to assess compliance with federal regulations and facility licensing requirements.

The facility was found deficient in multiple areas including fire safety barriers, hazardous area enclosures, sprinkler system maintenance, electrical equipment testing, gas equipment storage, and emergency preparedness planning. Deficiencies could affect all residents, staff, and visitors.

An unannounced annual recertification, annual relicensure, and complaint investigation survey was conducted at Pendleton Manor from August 29-30, 2022.

The facility was found to have deficiencies related to resident rights, notification of changes, grievance resolution, abuse and neglect investigations, reporting requirements, transfer/discharge notifications, quality of care including physician notification of weight changes, and food temperature management.

Complaint #26136 was unsubstantiated with no related or unrelated deficiencies cited. Complaint #26012 was substantiated with a related deficiency cited at F677 at past non-compliance.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules.

Pendleton Manor was found to be in substantial compliance with the applicable federal and state regulations. The review included plans of correction and credible evidence accepted in lieu of an onsite revisit, confirming compliance with previously cited deficient practices.

An unannounced annual re-certification and annual re-licensure survey was conducted at Pendleton Manor from May 10-11, 2021.

The survey identified deficiencies including failure to provide an individualized home-like environment due to improperly sized mattress overlays, failure to secure medication carts when unattended, and failure to maintain food preparation equipment in a clean and sanitary condition.

The inspection was conducted to assess compliance with fire safety and electrical system maintenance standards, as well as resident rights and emergency preparedness requirements.

The facility was found deficient in maintaining sealed smoke and fire barriers, with multiple unsealed penetrations observed. Additionally, the emergency generator lacked a remote manual stop switch external to the weatherproof enclosure. The facility was found in compliance with emergency preparedness requirements.

A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on August 4 - 6, 2020.

The facility was found in compliance with infection control regulations and CMS and CDC recommended practices to prepare for COVID-19.

A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on July 6-7, 2020.

The facility was found in compliance with 42 CFR 483.80 infection control regulations, 42 CFR 483.73 related to E-0024 (b)(6), and the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules.

Pendleton Manor was found to be in substantial compliance with the applicable federal and state regulations. A review of plans of correction and credible evidence was accepted in lieu of an onsite revisit, confirming compliance with previously cited deficient practices.

An unannounced annual re-certification and annual re-licensure survey was conducted at Pendleton Manor from 01/06/20 through 01/08/20 to assess compliance with federal regulations.

The survey identified deficiencies including failure to fully develop and implement nutritional and hospice care plans for residents, and incomplete documentation of pharmacy consultation reports regarding gradual dose reduction recommendations.

The inspection was conducted as a Standard Recertification Survey to assess compliance with federal and state regulations.

The facility was found deficient in emergency lighting testing, fire protection for hazardous areas, and portable fire extinguisher installation and maintenance. These deficiencies were acknowledged by the Administrator and Maintenance Supervisor during the exit interview.

The inspection was conducted as a complaint investigation survey concluding on 02/21/19, with review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

Pendleton Manor was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with the facility in substantial compliance with previously cited deficient practices.

Complaint reference number #21994. The complaint investigation survey concluded on 02/21/19 with the facility found in substantial compliance.

An unannounced complaint investigation was conducted at Pendleton Manor from 02/19/19 to 02/21/19 to investigate allegations related to infection control practices.

The investigation found the facility in substantial compliance overall, but identified a deficiency related to infection prevention and control. Specifically, Resident #16's CPAP mask was found lying open to the air on top of the CPAP machine, and staff were unaware of proper cleaning procedures. The facility lacked consistent cleaning and storage of CPAP equipment as per policy.

Complaint Reference #21994 was unsubstantiated with a related deficiency cited at F880 regarding infection prevention and control.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Division of Health Nursing Home Licensure Rule.

Pendleton Manor was found to be in substantial compliance with the applicable federal and state regulations. A review of plans of correction and credible evidence was accepted in lieu of an onsite revisit, confirming compliance with previously cited deficient practices.

An unannounced annual re-certification and annual re-licensure survey was conducted at Pendleton Manor from October 15, 2018 through October 18, 2018.

The survey identified multiple deficiencies including failure to maintain a safe, clean, and comfortable environment, inaccurate resident assessments, inadequate ADL care, failure to maintain continence care, incomplete pain management documentation, inadequate infection control during wound care, and a non-functioning resident call light.

The inspection was conducted to evaluate compliance with fire safety regulations and electrical equipment maintenance standards, including fire drills and testing of patient care related electrical equipment (PCREE).

The facility failed to ensure fire drills were held at unexpected times under varying conditions at least quarterly on each shift as required by NFPA 101, and failed to conduct proper electrical equipment testing and maintenance on PCREE in accordance with NFPA 99.

The document is a plan of correction related to a Quality Indicator and Licensure Survey concluding on 08/03/2017, accepted in lieu of an onsite revisit.

Pendleton Manor is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices addressed through plans of correction and credible evidence.

Unannounced annual Quality Indicator and State Licensure Surveys were conducted at Pendleton Manor from July 31, 2017 through August 3, 2017 to assess compliance with federal and state regulations.

The facility failed to ensure incidents of resident to resident sexual contact were reported to the state agency, thoroughly investigated, and interventions to prevent further occurrences were implemented. Additionally, medical records did not accurately document incidents of resident to resident sexual contact. These deficiencies affected two residents (#49 and #79) and had the potential to impact other residents.

The inspection was conducted as an annual survey to assess compliance with fire safety, electrical systems, and resident rights regulations.

The facility failed to perform fire drills at unexpected times and under varying conditions, failed to maintain electrical wiring according to NFPA standards, and failed to complete electrical testing for portable patient-care related equipment. The environmental services director acknowledged these deficiencies.

The document is a plan of correction related to a complaint investigation (#15871) and Quality Indicator and Licensure Surveys concluding on 07/27/16, accepted in lieu of an onsite revisit.

Pendleton Manor is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with previously cited deficient practices addressed.

Complaint Investigation (#15871) was reviewed and accepted with plans of correction and credible evidence in lieu of onsite revisit.

The inspection was conducted to assess compliance with the NFPA 101 Life Safety Code Standard, specifically regarding the installation and supervision of the automatic sprinkler system throughout the facility.

The facility failed to provide full protection with an approved, supervised automatic sprinkler system in the recently renovated 200 wing attic, which could affect all residents, staff, and visitors. This deficiency was observed and discussed with the Maintenance Supervisor during the visit.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, including smoke barriers, fire alarm systems, sprinkler systems, emergency generator maintenance, and electrical wiring safety.

The facility was found deficient in multiple areas related to life safety code compliance, including unsealed penetrations in smoke barriers, failure to maintain fire alarm and sprinkler systems properly, missing sprinkler protection in renovated areas, improper wiring and equipment maintenance, and failure to test generator battery electrolyte fluids weekly.

An unannounced complaint survey was conducted at Pendleton Manor, Inc. from August 25, 2015 to August 27, 2015 in response to Complaint #13925.

The complaint was unsubstantiated with no unrelated deficiencies cited during the investigation. The complaint sample consisted of 5 residents.

Complaint #13925 was unsubstantiated with no unrelated deficiencies cited.

An unannounced revisit was conducted at Pendleton Manor, Inc. from 07/13/15 to 07/15/15 for the Quality Indicator Survey concluding on 05/22/15.

The facility was found to be in substantial compliance with the previously cited deficient practices as reflected on the CMS-2567B.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards and other regulatory requirements related to fire safety, resident rights, and facility maintenance.

The facility was found deficient in multiple areas including resident room doors not resisting smoke passage due to gaps, improper sealing of smoke/fire barrier penetrations, failure to maintain sprinkler systems and gauges, presence of debris and paint on sprinkler heads, missing or loose escutcheons, and use of a prohibited portable space heating device in a resident area.

An unannounced annual Quality Indicator Survey was conducted at Pendleton Manor from May 18, 2015 through May 22, 2015 to assess compliance with federal regulations.

The facility was found deficient in multiple areas including failure to promote dignity and respect related to toileting assistance, failure to honor resident bathing preferences and frequency, failure to develop comprehensive care plans including physician orders, failure to implement care plan interventions for wheelchair safety, failure to prevent and timely treat pressure ulcers, insufficient nursing staff to meet resident needs, and failure to maintain sanitary food handling and infection control practices.

An unannounced complaint investigation was conducted at Pendleton Manor from July 22, 2014 to July 23, 2014 for Complaint Reference #11451.

The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule.

The allegations were unsubstantiated and no related or unrelated deficient practices were identified.

The document is a plan of correction related to a Quality Indicator and Licensure Survey for Pendleton Manor nursing facility, addressing previously cited deficient practices.

Pendleton Manor is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules. The facility submitted plans of correction and credible evidence accepted in lieu of an onsite revisit for the Quality Indicator and Licensure Surveys concluding on 02/27/14.

Unannounced annual Quality Indicator and State Licensure Surveys were conducted at Pendleton Manor from February 24, 2014 through February 27, 2014 to assess compliance with regulatory requirements.

The facility was found deficient in multiple areas including housekeeping and maintenance with damaged walls and furniture in resident rooms, failure to verify employee eligibility through the State nurse aide registry, undignified feeding practices, improper food holding temperatures, unsafe medication storage and handling, infection control breaches, and malfunctioning resident call lights in several rooms.

The inspection was conducted to assess compliance with the NFPA 101 Life Safety Code Standard, specifically regarding electrical wiring and equipment in accordance with NFPA 70, National Electrical Code.

The facility failed to ensure all junction boxes were provided with covers in six junction boxes located in the ceiling on three of five resident wings. The maintenance staff acknowledged the boxes did not have the required covers, and the administrator stated the required covers had already been ordered.

This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance of the facility.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).

Revisit to the Quality Indicator and Licensure Surveys conducted on 10/09/12.

The facility failed to ensure that a resident dependent on staff for activities of daily living (ADLs) received adequate grooming and personal hygiene care. Resident #37 was observed with uncombed hair, dirty fingernails, soiled face and clothing, and had missed a scheduled bath due to lack of bath aide staffing.

Annual Quality Indicator and Licensure Survey conducted from 07/30/12 to 08/03/12 to assess compliance with federal regulations for nursing facilities.

The facility was found deficient in multiple areas including management of resident personal funds, care planning and provision of ADL care, safety hazards related to water temperatures and fan cords, treatment and care for special needs such as respiratory equipment, food sanitation practices, drug storage, and infection control procedures.

The inspection was a routine survey to assess compliance with NFPA 101 Life Safety Code standards and other regulatory requirements for the nursing facility.

The facility was found deficient in maintaining self-closing smoke doors in the 500 wing, securing and properly identifying oxygen cylinders in storage, and maintaining battery-powered emergency lighting for the generator manual switch location.

The inspection was conducted as a complaint investigation referenced by State 12070 / ACTS 7035.

The complaint was found to be unsubstantiated with no citations issued.

Complaint Reference: State 12070 / ACTS 7035. Unsubstantiated complaint record with no citations.

The inspection was conducted in response to complaint reference #11051.

The complaint was unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #11051 was investigated and found to be unsubstantiated with no deficiencies cited.

The inspection was conducted based on substantiated complaints #10359 and #10378 regarding allegations of neglect and failure to report incidents properly.

The facility failed to immediately report allegations of neglect and the results of internal investigations to the proper State agencies for two residents (#52 and #36). Additionally, the facility failed to prevent significant weight loss and did not adequately document nutritional status or feeding assistance for residents #6, #36, and #67. Nursing documentation was insufficient regarding residents' eating habits and refusals of nourishment.

Complaint references #10359 and #10378 were substantiated. The facility failed to report neglect allegations and investigation results for residents #52 and #36 to State agencies as required.

The inspection was conducted as a substantiated complaint investigation related to employment of a nursing assistant with a felony conviction.

The facility failed to comply with state law by knowingly employing a nursing assistant with a felony conviction. The investigation included review of personnel records and interviews confirming the violation.

Complaint reference #10154 was substantiated with deficiencies cited related to employment of a nursing assistant with a felony conviction.

The inspection was conducted as a comprehensive annual survey to assess compliance with federal regulations related to resident rights, assessment accuracy, care planning, range of motion services, and clinical record maintenance.

The facility was found deficient in multiple areas including failure to accurately document a resident's skin abrasion in assessments, lack of coordinated care plans between hospice and facility staff, failure to provide restorative nursing services as ordered, and incomplete medication administration records.

The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, specifically regarding fire resistance rated construction and emergency power supply system testing.

The facility failed to provide a one-hour fire resistance rated assembly separating the existing building from an addition under construction, and the emergency power supply system was not load tested annually as required, with the last test conducted over 14 months prior to the inspection.

The inspection was conducted as a complaint investigation (#9283) concurrently with the facility's annual Medicare/Medicaid certification resurvey and State licensure inspection.

The facility had multiple deficiencies including failure to obtain written authorization for managing resident funds, inadequate employee screening for abuse, failure to conduct comprehensive assessments after significant changes in resident status, inaccurate resident assessments, failure to revise care plans, failure to provide necessary care for acute changes, inappropriate drug use, failure to act on pharmacist recommendations, inadequate infection control including delayed influenza vaccinations, and failure to maintain proper dishwasher sanitization.

Complaint reference #9283 was unsubstantiated with no related deficiencies cited.

This document is a Plan of Correction submitted by the facility in response to cited deficiencies during a prior inspection.

The report identifies deficiencies related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, including Medicaid-related information.

The inspection was conducted as a complaint investigation referenced by complaint #9267, which was substantiated with unrelated deficiencies cited.

The facility failed to revise the comprehensive care plan for one resident (#73) to accurately describe the care and services related to placing the resident's mattress on the floor to prevent falls. The care plan lacked details on how to move the resident, provide food/snacks in bed, and did not involve the resident's responsible party in the decision.

Complaint reference #9267 was substantiated with unrelated deficiencies cited.

The inspection was conducted in response to complaint references #9174 and #9183. The visit aimed to investigate substantiated and unsubstantiated complaints regarding facility policies and care practices.

The facility was found to have substantiated deficiencies related to failure to establish and maintain policies regarding admission, transfer, and discharge for residents requiring outpatient dialysis services. Resident #90 was refused readmission after hospital transfer for hemodialysis, and no written policy existed to support this restriction. The facility census was 89 at the time of inspection.

Complaint reference #9174 was substantiated with deficiencies cited. Complaint reference #9183 was unsubstantiated with unrelated deficiencies cited.

The inspection was conducted to assess the facility's compliance with sanitary conditions related to food preparation and service.

The facility failed to ensure food safety by allowing dust accumulation on kitchen equipment and failing to check food temperatures on the steam table prior to service on two separate occasions, potentially affecting all residents receiving food from the kitchen.

The inspection was conducted in response to complaint reference #9022.

The complaint was found to be unsubstantiated and no related deficiencies were cited during the investigation.

Complaint reference #9022 was unsubstantiated with no related deficiencies cited.

The inspection was conducted as a standard annual survey of Pendleton Manor nursing facility to assess compliance with federal regulations regarding resident rights, dignity, care, nutrition, infection control, clinical records, and other regulatory requirements.

The facility was found deficient in multiple areas including failure to treat residents with dignity during meal times, delayed response to call lights, unsecured medication carts, failure to follow dietary menus and recipes, inadequate hair restraints in dietary staff, improper handling of soiled linens, and inaccurate documentation of pneumococcal vaccination orders.

The inspection was conducted as a routine survey to assess compliance with NFPA 101 Life Safety Code standards and other regulatory requirements.

The facility failed to maintain corridor doors to close and latch properly, had obstructions in means of egress, failed to maintain the fire alarm system components properly, and did not maintain and inspect the range hood extinguishing system as required by NFPA standards.

Routine inspection of Pendleton Manor nursing facility to assess compliance with federal regulations including resident rights, care, safety, and facility environment.

The facility was found deficient in multiple areas including resident rights violations, failure to notify physicians of changes, inadequate staff treatment and supervision, failure to report and investigate abuse, dignity and respect issues, inadequate accommodation of resident needs, incomplete assessments and care plans, medication errors, infection control breaches, unsafe physical environment, pest control issues, inaccurate clinical records, and dietary deficiencies.

This document is a plan of correction related to a paper revisit survey conducted at Pendleton Manor nursing facility.

The document references a deficiency related to the facility's obligation to inform residents of their rights and services, but no detailed findings or severity levels are provided.

This document is a plan of correction related to a paper revisit survey conducted at Pendleton Manor nursing facility.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by federal regulations.

The inspection was conducted as part of an annual survey to assess compliance with federal regulations governing nursing facilities, including resident rights, social services, pre-admission screening, medication management, dietary services, infection control, and clinical record keeping.

The facility was found deficient in multiple areas including failure to appoint legal representatives for residents lacking capacity, inadequate psychosocial services related to hospice care, incomplete pre-admission screening, unnecessary drug use without proper documentation, insufficient dietary staff competency, failure to follow menus and recipes, poor food seasoning and presentation, unsanitary food preparation and service practices, incomplete medication regimen reviews by the pharmacist, failure to follow handwashing protocols during wound care, and incomplete clinical records regarding fluid restrictions.

The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, specifically regarding the maintenance and testing of the facility's emergency electrical power system.

The facility's emergency electrical power system was found not to be tested annually as required. The monthly load test performed was significantly below the required 30% of rated capacity, and no documentation of the required annual load bank test was available.

This document is a plan of correction related to a paper revisit survey conducted at Pendleton Manor.

The document includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).

The inspection was conducted to assess compliance with federal regulations regarding resident rights, food quality, physician visit frequency, discharge appeal rights, nursing staffing postings, and advance directives.

The facility was found deficient in multiple areas including failure to ensure a health care decision maker was properly appointed, food was not flavorful or palatable, physicians did not conduct timely face-to-face visits with residents, discharge notices lacked required appeal rights information, nursing staffing postings did not separately list RN and LPN hours, and a scope of treatment form was not properly signed by the health care surrogate.

The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.

Based on review of facility documentation, staff interview, and observations, the facility was determined to be in compliance with the NFPA 101 Life Safety Code, 2000 Existing Edition.

Paper revisit to review the facility's plan of correction following previous deficiencies.

The document summarizes deficiencies related to resident rights and notification requirements, specifically regarding informing residents of their rights and services. No new inspection findings are detailed beyond the plan of correction context.

The inspection was conducted as an annual survey to assess compliance with federal regulations governing nursing facilities, including resident rights, care planning, dietary services, medication administration, and facility operations.

The facility was found deficient in multiple areas including improper use of physical restraints, failure to develop comprehensive care plans, inadequate dietary services including menu planning and food safety, improper medication administration practices, inadequate supervision to prevent accidents, and failure to comply with staffing posting requirements.

The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.

Based on review of facility documentation, staff interview, and observations, the facility was determined to be in compliance with the NFPA 101, Life Safety Code; 2000 Existing Edition.

The inspection was conducted in response to complaint reference #2-4141.

The complaint was unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #2-4141 was investigated and found to be unsubstantiated with no deficiencies cited.

The inspection was conducted as a comprehensive annual survey to assess compliance with federal regulations regarding resident rights, staff treatment, quality of care, and staff qualifications.

The facility was found deficient in multiple areas including failure to conduct thorough background checks on employees, failure to provide ordered psychiatric evaluations and care such as TED hose application, inappropriate use of antipsychotic medication without proper assessment, and employing a nurse aide with an expired registration.

The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.

Based on review of facility documentation, staff interview, observations, and performance testing, the facility was determined to be in compliance with the Life Safety Code.

The inspection was conducted to review facility documentation, staff interviews, and observations to determine compliance with NFPA 101, Life Safety Code; 1967 Existing Edition.

The facility was found to be in compliance with the provisions of NFPA 101, Life Safety Code; 1967 Existing Edition.

The inspection was conducted as an annual survey to assess compliance with federal regulations regarding resident rights, quality of life, resident assessments, quality of care, dietary services, infection control, and other regulatory requirements.

The facility was found deficient in multiple areas including failure to provide reasonable accommodations for residents, inadequate resident assessments and care planning, failure to provide necessary care and services such as bowel management and feeding assistance, improper foot care, unsanitary food handling practices, and lapses in infection control procedures.

The inspection was conducted to assess compliance with professional standards of quality in medication administration and resident assessments, including adherence to physician orders for medications and daily weights.

The facility failed to discontinue a medication (Claritin) after the ordered duration had ended, and did not perform daily weights as ordered for residents with congestive heart failure and renal insufficiency, indicating lapses in medication management and resident monitoring.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, specifically regarding the fire rating of smoke barrier walls in the facility.

The facility was found to have incomplete smoke barrier walls that did not meet the required 30-minute fire rating. The addition to the dining room compromised the smoke barrier between the 400 Wing and the 300 Wing, with unsealed penetrations and exposed metal grid in the ceiling space.

The document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance of the facility.

The facility was found not to fully provide a safe and functional environment, including misuse of the main bath as a storage room limiting shower access, and water leaking from duct vents creating slipping and tripping hazards in corridors.

The inspection was conducted to evaluate compliance with the NFPA 101 Life Safety Code Standard, specifically assessing staff familiarity with emergency procedures during fire drills.

It was found that not all facility staff were familiar with emergency procedures related to fire drills. Specifically, during a fire drill on August 30, 2000, the staff announcement did not use the required term 'Code Red' as outlined in the facility's Fire and Emergency Procedures.

Annual inspection of Pendleton Manor nursing facility to assess compliance with federal regulations including resident rights, quality of care, dietary services, infection control, and staff treatment of residents.

The facility was found deficient in multiple areas including failure to timely report and follow up on abuse allegations, failure to promote resident dignity, incomplete care plans, improper medication administration techniques, inadequate supervision and accident prevention, failure to meet dietary needs and provide special eating equipment, and lapses in infection control procedures during gastrostomy tube medication administration.