GRAND RAPIDS, MI - Federal inspectors cited Pilgrim Manor nursing home for multiple serious violations during a July 2024 inspection, including severe understaffing that left residents waiting hours for basic care and dangerous delays in laboratory testing that prolonged resident suffering.
Residents Report Extended Wait Times for Essential Care
The most troubling findings centered on critically inadequate staffing levels that prevented residents from receiving timely assistance with basic daily needs. Multiple residents reported waiting between one to two hours for help with toileting, personal hygiene, and other essential care.
During interviews with federal inspectors, residents described distressing situations where they were forced to remain in uncomfortable positions for extended periods. One resident reported having to "lay in soiled briefs while she waited for staff assistance" due to staffing shortages that occurred "nearly every day."
Another resident experienced severe discomfort when forced to wait 30 minutes for toileting assistance due to her bowel condition. "When she has waited that long for assistance and held her bowel movement in too long, it was uncomfortable and she felt constipated," according to the inspection report.
The most alarming account came from resident council meeting minutes, where one resident reported sitting "on the toilet with the string pulled for 2 hours recently with no help."
Dangerous Staffing Patterns Documented by Multiple Sources
The inspection revealed systematic understaffing that compromised patient care across multiple areas. A Certified Nursing Assistant told inspectors that residents "were frequently missing their showers because the facility did not have the staff to provide showers." When only one CNA was assigned per unit, shower assistance became impossible to provide.
Medical staff also confirmed the severity of the situation. A registered nurse reported that staffing ratios were "often challenging," with the facility frequently operating with only two nurses covering three units. This arrangement made "completing any tasks difficult, especially administering medications on time."
Perhaps most telling was the observation from a medical doctor who reported witnessing "several staff members in tears due to being overwhelmed with their work load."
The understaffing created a cascade of care delays. One resident went 11 days without a shower, while another reported that staff would sometimes "turn off the call light without meeting their needs" when overwhelmed.
Critical Laboratory Testing Failures
Beyond staffing issues, the facility failed to ensure timely completion of essential medical testing. One resident experienced over two weeks of painful urination while waiting for urinalysis results that were delayed due to laboratory processing errors.
The resident's urine sample, ordered on July 12, 2024, was reportedly sent to the wrong laboratory due to confusion surrounding a recent change in lab providers. The facility's Director of Nursing confirmed that "education and training had not yet been provided to all nursing staff that were responsible for lab orders."
This delay meant the resident continued to experience discomfort and received delayed medical treatment. The attending physician confirmed that the resident "experienced a delay in treatment and care due to the facility not ensuring the urine sample was sent to correct lab and following up on the urinalysis results."
Food Safety and Temperature Control Violations
Inspectors also documented serious food safety violations that could impact all residents consuming meals from the facility's kitchen. During the inspection, all nine residents interviewed reported receiving cold food regardless of whether meals were served in rooms or the main dining room.
Temperature testing revealed significant problems with food service. Hot foods measured well below safe serving temperatures, with pasta and meat registering only 122°F and peas at 121°F when delivered to residents. Breakfast items fared even worse, with scrambled eggs at 124°F and sausage links dropping to just 103°F.
The cooling process for leftover foods also violated safety standards. Breakfast sausage was found at 109°F in the walk-in cooler, still tightly wrapped in plastic wrap an hour after being removed from the serving line. Federal food safety guidelines require hot foods to cool from 135°F to 70°F within two hours, but the facility's practices prevented proper heat dissipation.
Additional kitchen violations included exposed raw hamburgers in the freezer, heavily carbon-encrusted cooking pans, and a dishwashing machine operating below required temperatures. Open food containers lacked proper dating for discard times, creating potential for foodborne illness.
Inadequate Nutrition Support Between Meals
The inspection revealed that residents were not consistently receiving nighttime snacks, creating gaps of 13-14 hours between dinner and breakfast the following day. Eight of nine residents interviewed reported not receiving bedtime snacks, and when snacks were provided, choices were limited and often inappropriate for diabetic residents.
One resident reported observing nursing assistants "take pocketful of snacks for the residents and eat them all," though facility policy required nursing staff to distribute snacks to residents according to their dietary needs and preferences.
Pattern of Ongoing Problems
Resident council meeting minutes from throughout 2024 revealed that these problems were not isolated incidents but ongoing patterns that had been repeatedly brought to facility management's attention.
January 2024 minutes documented that "Many times food temp is still an issue, being too cold," while February minutes showed that "Most all residents at this meeting said 75% of the time all the food is cold."
The staffing crisis had also been consistently reported, with residents documenting in council meetings that they had "given up on the light and just yells for help until he is answered" and regularly waited "40-45 minutes before anyone comes to help her use the bathroom."
Medical Implications of Care Delays
The documented care delays pose serious health risks for nursing home residents, who often have complex medical conditions requiring timely interventions. Extended periods in soiled undergarments can lead to skin breakdown, urinary tract infections, and dignity-related psychological distress.
Delayed laboratory testing can result in untreated infections progressing to more serious conditions, including sepsis in vulnerable elderly populations. Urinary tract infections, when left untreated, can lead to kidney complications and systemic infections that may be life-threatening for frail residents.
Cold food temperatures below 140°F create ideal conditions for bacterial growth, potentially causing foodborne illnesses that can be particularly dangerous for elderly residents with compromised immune systems. The 13-14 hour gaps between substantial meals can lead to nutritional deficiencies and blood sugar instabilities, especially concerning for diabetic residents.
Regulatory Standards and Expectations
Federal nursing home regulations require facilities to maintain adequate staffing levels to meet residents' needs and ensure timely response to requests for assistance. The documented wait times of 1-2 hours for basic toileting needs clearly violate these standards.
Laboratory services must be completed in a timely manner to support proper medical care, and facilities are required to have systems in place to track and monitor pending orders. The confusion surrounding the lab provider change indicates inadequate oversight and training protocols.
Food safety regulations mandate that hot foods be maintained at temperatures above 140°F during service and that proper cooling procedures be followed to prevent bacterial growth. The documented violations represent serious breaches of these fundamental safety requirements.
These violations at Pilgrim Manor highlight the critical importance of adequate staffing, proper training, and systematic oversight in nursing home care. The facility's response to these citations and implementation of corrective measures will be essential for ensuring resident safety and dignity moving forward.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pilgrim Manor from 2024-07-25 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.