Cycle 1
Health 2024-05-01 · Fire 2024-05-01
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Franklin, WV
Pendleton Manor
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
68 Good Samaritan Drive, Franklin, WV
(304) 358-2322
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
89
Certified beds
Average residents
79
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-10-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.72
Registered nurse staffing
LPN hours / resident day
0.61
Licensed practical nurse staffing
Aide hours / resident day
2.76
Nurse aide staffing
Weekend hours
3.70
Weekend nurse staffing
RN turnover
12%
Annual RN turnover
Total nurse turnover
43%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.0 |
1.9
1.1 pts worse
|
1.9
1.1 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
1.9
0.8 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
96.7%
3.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.6%
2.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
4.5%
3.1 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.6% |
6.8%
4.2 pts better
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.2% |
6.6%
2.4 pts better
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.2% |
27.0%
8.8 pts better
|
19.6%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 20.9% |
15.5%
5.4 pts worse
|
16.7%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.0% |
19.5%
4.5 pts better
|
16.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.7% |
17.6%
0.1 pts worse
|
14.9%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.0% |
0.5%
1.5 pts worse
|
1.0%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
1.8%
1.4 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.3% |
22.4%
0.1 pts better
|
19.8%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
4.7%
0.4 pts worse
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.4% |
78.8%
14.6 pts better
|
81.7%
11.7 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.7% |
12.4%
5.3 pts worse
|
12.0%
5.7 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.8% |
1.1%
2.7 pts worse
|
1.6%
2.2 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.5% |
23.0%
5.5 pts worse
|
23.9%
4.6 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-30 · Fire 2022-08-30
9 health deficiencies
Top issue: Resident Rights (4 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2021-05-11 · Fire 2021-05-11
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-05-01
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-06-24
F · Potential for more than minimal harm
2024-05-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-24
F · Potential for more than minimal harm
2024-05-01
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-06-24
F · Potential for more than minimal harm
2024-05-01
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-01
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-01
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-01
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-06-24
F · Potential for more than minimal harm
2022-08-30
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-10-17
F · Potential for more than minimal harm
2022-08-30
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2022-10-17
F · Potential for more than minimal harm
2022-08-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-17
F · Potential for more than minimal harm
2022-08-30
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-08-30
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-08-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-10-17
C · Minimal harm
2021-05-11
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2021-07-13
C · Minimal harm
2021-05-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-07-13
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-05-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-30
E · Potential for more than minimal harm
2024-05-01
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-05-30
E · Potential for more than minimal harm
2024-05-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-05-01
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-05-01
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-05-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-05-01
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-05-30
E · Potential for more than minimal harm
2022-08-30
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-08-30
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-08-30
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-08-30
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-08-30
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-08-30
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-08-30
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-08-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-08-30
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-10-14
D · Potential for more than minimal harm
2021-05-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-06-02
D · Potential for more than minimal harm
2021-05-11
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2021-06-02
B · Minimal harm
2021-05-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-06-02
Penalties and ownership
What sits behind the stars
Ownership
Bennett, Ann
Corporate Director · Individual
Bowers, Gregory
Corporate Director · Individual
Bowers, Gregory
Corporate Officer · Individual
Harper, Kenneth
Corporate Director · Individual
Harper, Marshall
Corporate Director · Individual
Hevener, Cary
Corporate Director · Individual
Kropp, Randall
Operational/Managerial Control · Individual
Kropp, Randall
Corporate Officer · Individual
Mitchell, Cara
Corporate Officer · Individual
Pendleton Manor, Inc
Operational/Managerial Control · Organization
Sites, Patricia
Corporate Director · Individual
Stevens, Karen
Corporate Director · Individual
Vandevander, Lynn
Corporate Director · Individual
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#3
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4-star overall rating with 3-star inspections with 15 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
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