Pendleton Manor

In the surveyor’s words

From the most serious findings on record at Pendleton Manor, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880May 1, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF550Mar 2, 2026

  Based 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. Findings included: a) The facility's policy and procedure for The Dining Experience: Staff and Responsibilities stated, Staff should provide service that will help to make dining a special event that individual patients/residents look forward to and that will create lasting memories. On 02/25/26 at 12:25 PM in the Day Room/Sitting Room, four (4) of five (5) residents were served their lunch meal without their food being removed from their plastic trays. […]

• No harm, potential for more than minimal, patternF689Mar 2, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF804Mar 2, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF812Mar 2, 2026

  Based 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: 87Findings included:a) On 02/25/2026 12:36 PM During the initial kitchen visit and walk through with the Dietary Manager, who acknowledged the following:Freezer :-one box of opened frozen hamburger patties stored in an opened box with the inside plastic wrap left open to air-one box of opened frozen fish filets stored in an opened box with the inside plastic wrap left open to air-one box of sugar cookie dough stored in an opened box with the inside plastic wrap left open to air Pantry:-Tea bags not sealed and left… […]