A list of the most recent deficiencies for Pilgrim Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-17 | 2024-02-25 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-01-22 | 2024-02-12 | Y |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-01-22 | 2024-02-12 | Y |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-17 | 2024-01-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-22 | 2024-01-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-22 | 2024-01-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-22 | 2024-01-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-15 | 2023-03-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-15 | 2023-03-27 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-02-15 | 2023-03-27 | N |
| 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. | Health | 2023-02-15 | 2023-03-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-15 | 2023-03-27 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-15 | 2023-03-27 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-02-15 | 2023-03-27 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-03-06 | 2023-03-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-06 | 2023-03-23 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2023-03-06 | 2023-03-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-11-18 | 2019-12-09 | 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 | 2019-11-18 | 2019-12-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-11-18 | 2019-12-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-18 | 2019-12-09 | N |
