Pilgrim Manor
Inspection History Overview
Detailed Inspection Reports
Notice: These are official CMS inspection narratives containing detailed regulatory findings. This information is not available in searchable format anywhere else online.
Fines and Penalties by Year
2025 2 penalties totaling $43,140
Fine
Fine
2022 3 penalties totaling $24,750
Fine
Fine
Payment Denial
2020 1 penalties totaling $58,320
Fine
2018 1 penalties totaling $20,965
Fine
2017 1 penalties totaling $11,180
Fine
Health Violations by Year
2025 15 violations
Ensure services provided by the nursing facility meet professional standards of quality.
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.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Provide and implement an infection prevention and control program.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2024 23 violations
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Honor the resident's right to organize and participate in resident/family groups in the facility.
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.
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.
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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.
Provide safe and appropriate respiratory care for a resident when needed.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Provide timely, quality laboratory services/tests to meet the needs of residents.
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Protect each resident from the wrongful use of the resident's belongings or money.
2023 30 violations
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Provide and implement an infection prevention and control program.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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.
Keep residents' personal and medical records private and confidential.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2022 20 violations
Ensure services provided by the nursing facility meet professional standards of quality.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Provide and implement an infection prevention and control program.
Ensure staff are vaccinated for COVID-19
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
2021 14 violations
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure services provided by the nursing facility meet professional standards of quality.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Respond appropriately to all alleged violations.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2020 8 violations
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide and implement an infection prevention and control program.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
2019 5 violations
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2018 19 violations
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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.
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.
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Provide and implement an infection prevention and control program.
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Honor the resident's right to organize and participate in resident/family groups in the facility.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
2017 5 violations
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Respond appropriately to all alleged violations.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.