Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pendleton Manor during CMS and state inspections, most recent first.
Surveyors found multiple unsecured hazards in resident-accessible areas, including cleaning chemicals, food waste, and sharp or medical items. In one hall, residents could access a mini-kitchen where Scrubbing Bubbles and vinegar were stored under the sink and a manual can opener was left on the stovetop, while uncovered food waste carts were left unattended in dining and hallway areas used by residents. Elsewhere, oxygen tanks were improperly stored in a cubby without regulators or full/empty labels, Sani-Wipes were left on an unattended treatment cart, and a linen cart and an unlocked cabinet contained accessible lotions, hand sanitizer, and other supplies. An open, unattended shower room also contained an overflowing sharps container with razors, an open can of Scrubbing Bubbles, and an open whirlpool disinfectant container, all within easy reach of residents.
A facility failed to maintain dignity and respect during dining when four of five residents in a Day Room/Sitting Room were served lunch on plastic trays without the food being removed from the trays. An LPN confirmed the meal service was provided this way, despite the facility policy stating dining should be a special event residents look forward to.
Food was served at an unsafe temperature during meal delivery. Two residents reported that meals were cold, and during a meal pass on one hall, trays were delivered without a heated cart by only two staff members. The dietary manager checked the food at the time of service and found lasagna and vegetables well below the expected serving temperature, noting that the hall lacked a heated cart.
Improper food storage was observed in the kitchen and multiple nourishment areas. Opened frozen foods, cereals, tea bags, lunchmeat, crackers, and other items were left open to air, several foods lacked labels or dates, and a loaf of bread with green mold was found in a cabinet. Utensils were also stored in different directions, and the facility's food storage policy required foods to be kept in resealable containers with tight lids and labeled with the item name, date, and use-by date.
Infection control practices were not followed when two residents were observed with wheelchairs that had cracked or torn areas exposing padding, an EBP sign on a room door had no resident identification, and hand hygiene was not observed before lunch for multiple residents entering the dining room. An IP acknowledged the wheelchair condition was an infection control issue, and an RN confirmed the unmarked EBP sign.
A resident had a documented decline and later admission to hospice services, but the facility had no documentation that the MD was notified of the significant change or hospice-related change in condition. Notes reflected family attendance at the hospice admission and a later care conference identifying a nursing significant change due to hospice placement, yet the record still lacked evidence of physician notification.
Failure to Notify Ombudsman of Resident Transfer: A resident was transferred to the hospital, but the facility did not send the Notice of Transfer/Discharge form to the LTC Ombudsman and had no record that the Ombudsman was notified of the hospitalization. The SW confirmed the paperwork had been overlooked before surveyor intervention.
Failure to Document Meal Intake and Insulin Administration: A resident with type 1 DM and hyperglycemia had an order for Insulin Aspart after meals with dosing based on blood sugar and meal intake. The MAR showed multiple meal-time insulin administrations where the amount of food eaten and the number of units given were not documented, and the DON confirmed the missing documentation.
The facility failed to maintain an effective infection prevention program, lacking COVID-19 precaution signage at the entrance and on a resident's door. The water management plan was incomplete, missing documentation for Legionella control. Expired Sani wipes were found in a medication room, confirmed by an LPN.
The facility failed to update PASARRs for three residents with new diagnoses of Major Depressive Disorder. Despite being diagnosed during their stay, the PASARRs did not reflect these changes, as confirmed by the DON and social workers. This oversight was identified during a survey review of six residents.
A toaster was found plugged in and operable in the 500 Hall kitchenette, posing an accident hazard to residents. The toaster was accessible to passersby, and its operability was confirmed when the coils glowed red upon activation. The DON acknowledged the hazard during an interview.
A facility failed to protect a resident's medical information when a restorative note detailing a Parkinson's diagnosis was left visible on a rolling workstation desk in a hallway. An RN confirmed the note was improperly exposed, and the DON acknowledged the breach of confidentiality.
A facility failed to update the PASARR for a resident diagnosed with cerebral palsy, as identified during a survey. The resident was admitted with cerebral palsy as the principal diagnosis, but this was not reflected in the PASARR. Interviews with the DON and a social worker confirmed the omission and the lack of a new PASARR to include the diagnosis.
A facility failed to ensure proper collaboration with hospice services for a resident with dementia. The resident's hospice documentation lacked an active care plan or collaborating documentation. The DON confirmed the absence of a coordinated plan of care with the hospice provider and had to request the necessary documentation.
The facility failed to maintain complete and accurate POST forms for two residents. One resident's form was signed by their legal representative but not dated, while another's form was signed and dated by the legal representative but lacked the physician's signature and date. These deficiencies were confirmed by a social worker.
Unsecured Hazardous Materials and Equipment in Resident-Accessible Areas
Penalty
Summary
The deficiency involves the facility’s failure to keep resident-accessible areas free from accident hazards and hazardous products. On the 500 hall, residents had access to a mini-kitchen where Scrubbing Bubbles and a gallon of white vinegar were stored under the sink, and a manual can opener with sharp edges was left on the stovetop. In the adjacent dining area, a cart with two uncovered metal cans containing food waste was left unattended for about 20 minutes while residents were present. Later, two unattended waste carts with uncovered lunch waste were also observed in the 200 hallway, an area actively used by residents. These conditions occurred while residents were under the care and control of the facility. Additional hazards were identified in multiple other areas. On the 100 hall, two single resident oxygen tanks without regulators and without full/empty labels were stored in a cubby area rather than a designated storage area. On the 400 hall, Sani-Wipes (purple top), which are poisonous if ingested and can cause chemical burns, were left unattended on a treatment cart near the nurses’ station. On the 500 hall, a linen cart side pouch contained zinc skin tubes, moisturizer, and calamine lotion packets, and a large wooden cabinet labeled “staff only” in the living area was found unlocked with linens, soap, incontinence briefs, hand sanitizer, alcohol wipes, and skin prep pads inside. In a shower room found open and unattended during resident interviews, a table held an overflowing sharps container with three blue razors, an opened can of Scrubbing Bubbles, and an opened container of whirlpool disinfectant, all easily accessible to residents.
Dining Service Did Not Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure the resident environment maintained or enhanced dignity and respect during the dining experience. The facility's policy and procedure for The Dining Experience: Staff and Responsibilities stated that staff should provide service that will help make dining a special event that 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 of five residents were served lunch without their food being removed from their plastic trays. An LPN confirmed that the residents were served their lunch meal on a plastic tray.
Food Served at Unsafe Temperature During Meal Service
Penalty
Summary
Food and drink were not maintained at a safe, appetizing temperature during meal service. Resident #79 stated that the food was terrible and had been cold, and Resident #38 stated that the food was sometimes too cold when it arrived. During a meal pass on the 400 hall, meals were delivered without a heated cart and only two staff members were passing all trays to residents on that hall. The dietary manager checked food temperatures at the time of service and found lasagna at 57 degrees Fahrenheit and vegetables at 53 degrees Fahrenheit, then confirmed that the food was not served at 120 degrees Fahrenheit at time of service. The dietary manager stated there were not enough heated carts for the entire facility, and the 400 hall was the only hall without a heated cart that day.
Improper Food Storage in Kitchen and Nourishment Areas
Penalty
Summary
Food was not properly stored in the facility kitchen and nourishment areas during observations with the Dietary Manager and the Facility Administrator. In the kitchen freezer, opened boxes of frozen hamburger patties, fish filets, and sugar cookie dough were stored with the inner plastic wrap left open to air. In the pantry, tea bags and plastic bags of All Bran, Wheats, and Creme of Wheats cereals were left unsealed and open to air. Utensil drawers also contained utensils stored in different directions, including a plastic box of utensils taken directly from the dishwasher and stored in different directions. Additional observations in the 500 Hall nourishment room and dining area found a Klondike ice cream bar in the freezer without a label or date, lunchmeat in the refrigerator left open to air, and an unopened sleeve of Ritz crackers in a cabinet without a date or label. In the 300 Hall nourishment room, an opened sleeve of Ritz crackers was found without a dated label. In the dining room storage cabinets, an opened box of All Bran cereal was left on the counter with the inner package open to air, and plastic packages of Corn Flakes, Toasted Oats, and Raisin Bran were left open to air in the cabinet. In the 300 Hall nourishment room/dining area, the freezer contained a pint of Ben and Jerry's ice cream, frozen toaster pastries, Banquet sausage gravy/biscuits, Tostitos pizza rolls, and individual ice cream bars without labels or dates, and the upper cabinet contained Honey Nut Cheerios bars without a label or date, a loaf of bread with green mold, and a lone stick of gum with no package. The facility food storage policy stated non-perishable and perishable foods are to be stored in resealable containers with tightly fitting lids and labeled with the item name, date, and use-by date.
Infection Control Program Not Followed
Penalty
Summary
The facility failed to maintain and follow an infection prevention and control program per professional standards. During observation and interview, Resident #17 was found sitting in a wheelchair with cracks and tears on both armrests exposing the padding, and Resident #38 was observed with a wheelchair that had a tear with exposed padding on the backrest. The infection preventionist acknowledged that the two wheelchairs had exposed padding and stated it was an infection control issue. During a routine walk-through, an Enhanced Barrier Protection sign was observed on the door of a room on the 400 resident hall, but the sign had no markings or indication of which resident the precautions were for. RN #149 confirmed there was no marking on the sign to identify the resident it pertained to. In the main dining room, no hand hygiene was observed before the lunch meal for residents entering the dining area, including six ambulatory residents using assistive devices and five residents propelling wheelchairs. A nursing aide confirmed that hand hygiene had not been completed for the residents in the dining room.
Failure to Notify Physician of Resident’s Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for Resident #47 related to admission to hospice services. The facility policy stated that it promptly notifies the resident, attending physician, and resident representative of changes in the resident's medical or mental condition and/or status. On 09/24/25, a progress note documented a decline with nursing reporting a significant change, but no documentation was found showing physician notification of the decline or significant change. A nursing progress note dated 10/14/25 documented admission to hospice services with family in attendance, and a 10/29/25 care conference note documented a nursing significant change due to hospice placement. On 02/26/26, the Administrator verified there was no documentation of physician notification for the resident's change in condition for hospice, and on 03/02/26 the state surveyor requested documentation of physician inclusion in the hospice decision-making process and notification of the change in condition, but no additional information was obtained.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to send a copy of the Notice of Transfer/Discharge form to the Long-Term Care Ombudsman when Resident #7 was transferred to an acute care hospital. An electronic medical record review on 03/01/2026 at 12:08 PM showed that Resident #7 had been transferred to the hospital on [DATE], but there was no evidence in the resident’s record that the Ombudsman had received the Notice of Transfer/Discharge paperwork or had been notified of the hospitalization. During an interview on 03/02/26 at 10:40 AM, the Social Worker confirmed that the Notice of Transfer/Discharge paperwork had not been shared with the Long-Term Care Ombudsman prior to surveyor intervention and stated that it had been accidentally overlooked.
Failure to Document Meal Intake and Insulin Administration
Penalty
Summary
Resident #7, who had a physician order for Insulin Aspart 10 units subcutaneously three times daily for type 1 diabetes mellitus with hyperglycemia, was to receive the insulin immediately after each meal with dose adjustments based on blood sugar and the amount of meal consumed. The order specified that if blood sugar was greater than 400, the full 10 units were to be given regardless of intake, and if more than 50% of the meal was eaten, the full dose was to be given; if 50% or less was eaten, half the dose was to be given. A review of the MAR showed multiple meal-time insulin administrations in which the percentage of the meal consumed and the number of units administered were not recorded. These omissions occurred on numerous breakfast, lunch, and dinner entries across several dates. During interview, the DON confirmed that the MARs on the listed dates and times did not document the meal percentage consumed or the number of insulin units administered.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during a survey. At the facility's front entrance, there was no precautionary signage to inform visitors about the presence of COVID-19 within the building. This was confirmed by the Director of Nursing during an interview. Additionally, in room [ROOM NUMBER], where two residents were on COVID-19 precautions, there was a lack of precautionary signage on the door, which was also verified by the Director of Nursing. Further deficiencies were noted in the facility's water management plan, which lacked documentation to prevent the growth of waterborne pathogens. The facility did not maintain a flow diagram or text identifying the building's water systems for Legionella control measures, nor was there documentation regarding the flushing of water systems in dead leg areas. The Maintenance Director confirmed these omissions. Additionally, expired Sani wipes were found in the 100-hall medication room, which was acknowledged by an LPN during an interview.
Failure to Update PASARRs for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to complete new Pre-Admission Screening and Resident Review (PASARR) assessments for residents with newly diagnosed serious mental disorders. This deficiency was identified for three out of six residents reviewed during the survey process. Resident #11 was admitted to the facility and later diagnosed with Major Depressive Disorder, but the PASARR submitted did not include this new diagnosis. Interviews with the Director of Nursing (DON) and Social Worker (SW) confirmed the absence of the diagnosis on the PASARR and acknowledged that no new PASARR had been completed to reflect the change. Similarly, Resident #28 was diagnosed with Major Depressive Disorder during their stay, but this diagnosis was not included in their PASARR. The DON and SW confirmed the omission and the lack of a new PASARR. Additionally, Resident #49, who was diagnosed with Major Depressive Disorder, Recurrent, did not have a new PASARR completed to capture this diagnosis. The SW confirmed that no updated PASARR was on file for this resident. These findings indicate a failure to update PASARRs to reflect significant changes in residents' mental health diagnoses.
Toaster Hazard in 500 Hall Kitchenette
Penalty
Summary
The facility failed to maintain an environment free from accident hazards in the 500 Hall kitchenette, where a toaster was found plugged in and operable. This posed a potential risk to all residents residing on the 500 Hall. During an observation, it was noted that the toaster was accessible to anyone passing by, and when the lever was pushed down, the coils glowed red, indicating it was fully functional. The Director of Nursing confirmed the toaster as an accident hazard during an interview conducted shortly after the observation.
Confidentiality Breach of Resident's Medical Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical information. On May 1, 2024, at 7:54 AM, a paper restorative note was observed on a rolling workstation desk in the 400 Hallway, which was accessible to passersby. This note contained sensitive information about a resident, specifically indicating a risk for decline in range of motion related to a diagnosis of Parkinson's. At 8:00 AM, RN #5 confirmed that the note was visible and should not have been left unattended. Subsequently, at 8:15 AM, the Director of Nursing acknowledged that leaving the restorative note on the workstation desk compromised the privacy of the resident's medical record.
Failure to Update PASARR for Resident with Cerebral Palsy
Penalty
Summary
The facility failed to complete a new Pre-Admission Screening and Resident Review (PASARR) for a resident diagnosed with a possible serious mental disorder. This deficiency was identified during a survey process where one out of six residents reviewed for PASARRs was affected. The resident in question, identified as Resident #23, was admitted to the facility with a principal diagnosis of cerebral palsy, which was entered into the system on February 6, 2023. However, upon reviewing the PASARR for this resident, it was found that the diagnosis of cerebral palsy was not included. Interviews with the Director of Nursing and a Social Worker confirmed the absence of the cerebral palsy diagnosis on the PASARR and acknowledged that no new PASARR had been completed to reflect this diagnosis.
Failure to Collaborate with Hospice Services
Penalty
Summary
The facility failed to ensure that a resident receiving hospice services received treatment and care in accordance with professional standards of practice. Specifically, the facility did not collaborate effectively with hospice services for a resident diagnosed with dementia. The medical record review revealed that the resident was admitted to hospice services, but the hospice documentation notebook lacked an active care plan or collaborating documentation from hospice services. During an interview, the Director of Nursing confirmed that there was no current coordinated plan of care with the hospice provider, and she had to contact hospice services to have the necessary documentation faxed to the facility.
Incomplete and Inaccurate POST Forms
Penalty
Summary
The facility failed to ensure complete and accurate medical records, specifically regarding the Physician Orders for Scope of Treatment (POST) forms. For two out of three records reviewed, the POST forms were found to be incomplete or inaccurate. In the case of one resident, the POST form was signed by the resident's legal representative but was not dated, rendering it legally invalid. The physician had signed and dated the form, but the absence of the legal representative's date made it incomplete. In another instance, a resident's POST form was signed and dated by the legal representative, but the physician had neither signed nor dated the form, also making it legally invalid. These deficiencies were confirmed during interviews with a social worker, who acknowledged the forms' invalidity.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Franklin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bridgewater Home , Inc. | 27.7 mi | ★★★★★ | 10 | 0 |
| Vmrc, Complete Living Care | 29.3 mi | ★★★★★ | 0 | 0 |
| Grant Rehabilitation And Care Center | 29.5 mi | ★★★★★ | 13 | 0 |
| Blue Ridge Rehabilitation And Nursing | 29.7 mi | ★★★★★ | 2 | 0 |
| Sunnyside Presbyterian Retirement Community | 30.2 mi | ★★★★★ | 2 | 0 |
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