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Deficiency Records for Pilgrim Place Health Services Center
View the most recent health deficiencies and inspection results for Pilgrim Place Health Services Center. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Pilgrim Place Health Services Center. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-12-05 | 2025-12-29 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2025-12-05 | 2025-12-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2025-12-05 | 2025-12-29 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2025-12-05 | 2025-12-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2025-12-05 | 2025-12-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2025-12-05 | 2025-12-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-12-05 | 2025-12-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-12-05 | 2025-12-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-12-05 | 2025-12-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-12-05 | 2025-12-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-12-05 | 2025-12-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-12-05 | 2025-12-26 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2025-12-05 | 2025-12-26 | N |
| Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | Health | 2025-12-05 | 2025-12-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-12-05 | 2025-12-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-12-05 | 2025-12-22 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2025-12-05 | 2025-12-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-11-18 | 2025-11-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-11-18 | 2025-11-26 | Y |
| Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Health | 2025-09-12 | 2025-10-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-07-02 | 2025-07-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-11-20 | 2024-12-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-11-20 | 2024-12-09 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-10-18 | 2024-11-20 | 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 | 2024-10-18 | 2024-11-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-10-18 | 2024-11-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-10-18 | 2024-11-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-10-18 | 2024-11-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-10-18 | 2024-11-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-10-18 | 2024-11-20 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-10-18 | 2024-11-10 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-10-18 | 2024-11-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-10-18 | 2024-11-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-10-18 | 2024-11-06 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-10-18 | 2024-11-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-10-18 | 2024-11-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-10-18 | 2024-10-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-10-18 | 2024-10-28 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-10-18 | 2024-10-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-10-18 | 2024-10-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-10-18 | 2024-10-23 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-10-18 | 2024-10-21 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-10-18 | 2024-10-21 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-10-18 | 2024-10-21 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-08-02 | 2024-09-09 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-07-03 | 2024-07-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-06 | 2023-11-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-06 | 2023-11-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-06 | 2023-11-13 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-06 | 2023-11-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-06 | 2023-11-13 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-10-06 | 2023-11-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-06 | 2023-11-13 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-10-06 | 2023-11-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-06 | 2023-11-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-06 | 2023-11-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-06 | 2023-11-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-06 | 2023-11-13 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-10-06 | 2023-11-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-06 | 2023-11-13 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-10-06 | 2023-11-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-06 | 2023-11-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-29 | 2023-09-22 | Y |