Pilgrim Manor

In the surveyor’s words

From the most serious findings on record at Pilgrim Manor, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 23, 2024

  Based on review of the clinical record, review of facility documentation, and interviews for 4 of 5 residents (Resident #304) reviewed for accidents, the facility failed to appropriately supervise a resident resulting in a fall with a major injury. The findings include: Resident #304 's diagnoses included dementia, anxiety, history of a transient cerebral ischemic attack (TIA), atrial fibrillation, and blindness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #304 was severely cognitively impaired and required extensive assistance for bed mobility, transfers, and personal hygiene. […]

• Actual harm, isolatedF689Feb 8, 2021

  Based on clinical record reviews, facility documentation review, facility policy review, and interviews for one of three residents (R #1) reviewed for accidents, the facility failed to ensure assistance was provided in accordance with the plan of care to prevent a fall with an injury. The findings include: R #1's diagnoses included [CONDITION(S)], muscle weakness, and lumbar vertebra compression fracture. A physician's order dated 8/10/20 directed to ambulate R #1 two times a day, fifty to seventy feet with contact guard with one assist and a rolling walker, to use a gait belt and a wheelchair to follow. […]

• No harm, potential for more than minimal, isolatedF684Dec 16, 2025

  Based on review of the clinical record, facility documentation, facility policy and interviews for 1of 2 residents (Resident #61) reviewed for indwelling catheter, the facility failed to obtain a complete physician's order for the indwelling catheter including insertion and ongoing care and management after a voiding trial failed. The findings include:Resident #61 was admitted to the facility in 10/2025 with diagnoses that included abscessed lung with pneumonia and empyema (pus in the pleural space around the lung). The care plan dated 10/6/25 identified Resident #61 was at risk for skin breakdown related to incontinence, impaired mobility and co-morbid conditions. […]

• No harm, potential for more than minimal, isolatedF689Dec 16, 2025

  Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 residents (Resident #19 and 24) who required supervision with eating, the facility failed to ensure the appropriate supervision was provided during eating. The findings include: Resident #19 was admitted to the facility in September 2024 with diagnoses that included oral phase dysphagia and cognitive communication deficit. The quarterly MDS dated [DATE] identified Resident #19 had moderately impaired cognition, required supervision or touching assistance with eating, and did not have a swallowing disorder. […]

• No harm, potential for more than minimal, isolatedF756Dec 16, 2025

  Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 residents (Resident #3) reviewed for unnecessary medications, the facility failed to ensure the provider adequately addressed pharmacy recommendations for a resident receiving a medication that should be administered before meals. The findings include:Resident #3 was admitted to the facility in February 2025 with diagnosis that included diabetes type ll. The care plan dated 2/26/25 identified Resident #3 was at risk for low/high blood sugars related to diabetes type II. […]