Pilgrim Manor Skilled Nursing and Rehabilitation

Inspectors wroteBased on record review and interviews, the facility failed to follow physician's orders for 1 (Resident #47) of 1 (Resident #47) resident reviewed for UTI.

Inspectors wroteBased on medication administration observations, record reviews, and interviews, the facility failed to ensure the facility was free from a medication error rate of 5% or greater. The facility had a 14.29% medication error rate with 4 medication errors out of 28 opportunities.

Inspectors wroteBased on record reviews and interview the facility failed to inform and provide written information to residents or resident's representative concerning the right to formulate an advance directive for 2 (#38, #96) of the 48 sampled residents.

Inspectors wroteBased on record review and interview the facility failed to revise the care plan to reflect changes of a resident refusing medication/treatment for 1 (#31) of 1 sampled resident reviewed for care planning.

Inspectors wroteBased on observations, interview and record review the facility failed to provide nutritional and hydration care and services for 1(#57) of 5 (#4, #7, #13, #14 and 57) resident reviewed for nutrition. The facility failed to provide care and services for resident #7 consistent with the resident's comprehensive assessment resulting in weight loss.

Inspectors wroteBased on observation, interview and record review the facility failed to use infection control standards of practice for 1(#7) of 5 (#4, #7, #13, #14 and 57) residents reviewed for nutrition by not providing proper placement of a resident's gastrostomy tubing to prevent an increased risk of contamination and infection. Resident #7's gastrostomy tubing with the cap or cover was attached to the feeding pump tubing laying on the floor. Observation on 02/23/2026 at 12:50 p.m. with S4 LPN revealed Resident #7's PEG tube was disconnected. The gastrostomy tubing extended from Resident #7's abdomen did not have a cap or cover; it was opened. The cap or cover attached to the feeding pump tubing laying on the floor. S4 LPN removed the cap or cover from the floor and attached it to Resident #7's gastrostomy tube. During an interview on 02/23/2026 at 12:50 p.m. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to use a Hoyer lift, as determined necessary by the resident's comprehensive care plan, during a transfer from the resident's bed to wheelchair for 1 (#1) of 3 (#1, #2, #3) sampled residents which resulted in a right humeral neck fracture. The deficient practice resulted in harm for Resident #1 on 07/14/2025 at approximately 10:30 a.m. when S6 agency CNA (Certified Nursing Assistant) transferred Resident #1 from the bed to a wheelchair with a stand and pivot method without utilization of a Hoyer lift. Resident #1 had an onset of acute pain to her right arm/shoulder and reported her right arm hit the wheelchair armrest during transfer. Resident #1 was care planned for activities of daily living self-care deficit with intervention of dependent in transferring with the use of Hoyer lift. [...]

Inspectors wroteBased on record review, observations and interview, the facility failed to ensure a resident remained free from neglect when nursing staff failed to use a Hoyer lift to transfer 1 (Resident #F3) of 4 (Residents #F1, #F2, #F3, and #F4) sampled residents who required a mechanical lift for transfers.

Inspectors wroteBased on record reviews, observations and interviews, the facility failed to provide services that met professional standards for 2 (#102, #105) of 26 sampled residents. The facility failed to ensure safe oral medication administration practices by leaving medication at the bedside.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide respiratory care consistent with professional standards of practice for 2 (#27, #224) out of 2 (#27, #224) residents reviewed for respiratory services. The facility failed to: 1. Change the humidification bottle and nasal cannula weekly as ordered for Resident #27, and 2. Ensure oxygen tubing was dated, and humidification was administered with oxygen for Resident #224.

Inspectors wroteBased on observations and interviews, the facility failed to ensure dietary services were provided in a safe, sanitary environment to prevent contamination and food borne illness for the 121 residents served a meal tray from the kitchen per the Dietary Manager. The facility failed to ensure frozen meat was thawed following accepted practices.

Inspectors wroteBased on record review and interview, the facility failed to electronically submit accurate payroll information for direct care staffing as required.

Inspectors wroteBased on record review, video footage review, and interviews, the facility failed to protect the resident's right to be free from deprivation of goods and services by staff for 1 (#1) of 3 (#1, #2, #3) sampled residents when staff failed to utilize a Hoyer lift during a transfer. The deficient practice resulted in an immediate jeopardy for Resident #1 on 11/17/2024 when Resident #1 was transferred from a Geri chair to the bed without utilization of a Hoyer lift. Resident #1 was transferred to a local hospital related to a left lower leg wound which had adipose tissue and bone exposed. Review of Resident #1's hospital record revealed, Resident #1 was admitted with the primary diagnosis type I or II open non-displaced spiral fracture of shaft of left fibula with a laceration to distal LLE (left lower extremity) above the ankle mortis with exposed fibula. [...]

Inspectors wroteBased on record review, video footage review, and interviews, the facility failed to ensure a resident received adequate assistance to prevent accidents for 1 (#1) of 3 (#1, #2, #3) residents reviewed for transfers by failing to follow Resident #1's plan of care. The deficient practice resulted in an immediate jeopardy for Resident #1 on 11/17/2024 when Resident #1 was transferred from a Geri chair to the bed without utilization of a Hoyer lift. Resident #1 was transferred to a local hospital related to a left lower leg wound which had adipose tissue and bone exposed. Review of Resident #1's hospital record revealed, Resident #1 was admitted with the primary diagnosis type I or II open non-displaced spiral fracture of shaft of left fibula with a laceration to distal LLE (left lower extremity) above the ankle mortis with exposed fibula. [...]

Inspectors wroteBased on record review, video review, and interviews the facility failed to supervise a cognitively impaired resident from exiting the facility for 1 (Resident #1) of 9 ( #1, #2, #3, #4, #5, #6, #7, #8 and #9) sampled residents reviewed for elopement. This deficient practice resulted in an Immediate Jeopardy on 07/23/2024 at 5:55 p.m. when Resident #1, a severely cognitively impaired resident who was ambulatory, was unsupervised and eloped from the facility. Resident #1 walked out of the front entrance of the facility after S5Evening Receptionist remotely released the front sliding doors to an open position for Resident #1 to exit. Staff had not realized Resident #1 eloped from the facility until 07/23/2024 at approximately 7:30 p.m., when the search began and local police and Resident #1's RP (Responsible Party) were notified. [...]

Inspectors wroteBased on record review, video review, an interviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently by failing to implement a system to provide quality care to meet the needs of each resident by failing to: 1. Ensure a process was in place to prevent a cognitively impaired resident from exiting the facility for 1 (Resident #1) of 9 (#1, #2, #3, #4, #5, #6, #7, #8 and #9) sampled residents reviewed for elopement. and 2. Ensure the nursing staff possessed the competency to accurately assess a resident for an elopement risk. The lack of administrative oversight resulted in an Immediate Jeopardy on 07/23/2024 at 5:55 p.m. when Resident #1, a severely cognitively impaired resident who was ambulatory, was unsupervised and eloped from the facility. [...]

Inspectors wroteBased on record reviews, and interviews the facility failed to ensure the nursing staff possessed the competency to accurately assess a resident for elopement risk for 1 (Resident #1) of 9 ( #1, #2, #3, #4, #5, #6, #7, #8 and #9) sampled residents reviewed for elopement. This deficient practice resulted in an Immediate Jeopardy on 07/23/2024 at 5:55 p.m. when Resident #1, a severely cognitively impaired resident who was ambulatory, was unsupervised and eloped from the facility. Resident #1 walked out of the front entrance of the facility after S5Evening Receptionist remotely released the front sliding doors to an open position for Resident #1 to exit. Staff had not realized Resident #1 eloped from the facility until 07/23/2024 at approximately 7:30 p.m. [...]

Inspectors wroteBased on record review and interviews the facility failed to ensure grievances/complaints had been documented and investigated. The facility failed to follow their policy for reporting and investigating grievances for 1 (#1) of 4 (#1, #2, #3, #4) sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents and/or the resident's representative were provided with written information concerning advance directives and/or the option to formulate an advanced directive for 14 (#1, #3, #20, #21, #22, #24, #28, #40, #45, #50, #58, #65, #67, #74) of 15 (#1, #3, #20, #21, #22, #24, #28, #33, #40, #45, #50, #58, #65, #67, #74) residents reviewed for Advanced Directives.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure resident assessments were transmitted within the required timeframe for 3 (#88, #60, #49) of 19 residents reviewed for assessments out of a total of 28 sampled residents.

Inspectors wroteBased on record review, observations and interviews the facility failed to ensure residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to ensure oral care was provided for 2(#30, #109) of 4(#1, #30, #109, #111) residents reviewed for ADLs.

Inspectors wroteBased on record review and interview the facility failed to ensure wound care treatments were completed as ordered by a physician for 2 (#20, #106) of 4 (#20, #30, #74, #106) residents reviewed for pressure ulcer/injury.