Deficiency Records for Pilgrim Manor Skilled Nursing and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Pilgrim Manor Skilled Nursing and Rehabilitation. 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? |
|---|---|---|---|---|
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-06-07 | 2023-06-08 | 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 | 2023-01-31 | 2023-02-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-31 | 2023-02-01 | N |
| 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 | 2023-01-31 | 2023-02-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-31 | 2023-02-01 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-11-22 | 2022-11-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-22 | 2022-11-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-22 | 2022-11-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-22 | 2022-11-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-09 | 2022-03-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-09 | 2022-03-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-09 | 2022-03-25 | 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 | 2022-02-09 | 2022-03-25 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-02-09 | 2022-03-25 | 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 | 2022-02-09 | 2022-03-25 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-18 | 2021-12-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-18 | 2021-12-10 | Y |
| 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 | 2020-02-19 | 2020-04-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-02-19 | 2020-04-02 | N |
| 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 | 2020-02-19 | 2020-04-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-02-19 | 2020-04-02 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2020-02-19 | 2020-04-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-19 | 2020-04-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-19 | 2020-04-02 | N |
