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, isolatedF691Feb 13, 2026

  Based on interview, observation and record review, the facility failed to assess, notify the family and provider and document the change in the medical record after a resident developed blood in her colostomy (an opening in the abdominal wall, connecting the colon to the outside of the body to divert waste and gas) bag for 1 of 1 residents reviewed for colostomy care. This deficient practice resulted in a delay of treatment for a gastrointestinal bleed (GI) and anemia (low hemoglobin) and unexpected hospitalization. (Resident J) Finding includes: During an interview on 2/9/2026 at 12:02 P.M., Resident J indicated a staff member had found blood and blood clots in her colostomy bag and that the employee had taken a picture of the blood to show the nurse. […]

• Actual harm, isolatedF684Nov 27, 2024

  Based on record review and interview, the facility failed to follow bowel movement protocols. This resulted in the resident obtaining an ileus (a painful obstruction of the ileum or other part of the intestine) for 1 of 3 residents reviewed for quality of care. (Resident K) Finding includes: A record review for Resident K was completed on 11/26/2024 at 10:16 A.M. Diagnoses included, but were not limited to: Alzheimer's disease and constipation. The Quarterly Minimum Data Set (MDS) assessment, completed on 6/25/24 indicated the resident was severely cogntively impaired, was incontinent of her bladder and continent of her bowels and required some partial staff assistance for personal hygiene needs. […]

• No harm, potential for more than minimal, widespreadF812Feb 13, 2026

  Based on observation and interview, the facility failed to prepare and serve food under sanitary conditions related to staff hygiene in the kitchen and food temperature of hall trays for 1 of 1 kitchen areas observed. This issue had the potential to affect 62 of 62 residents who resided in the facility and received food from this dietary area.Findings include:During an interview, on 2/11/2026 at 11:20 A.M., the Dietary Manager indicated food remained on the steam table until it was plated or put on the resident meal trays.During an observation, on 2/12/2026 at 11:59 A.M. […]

• No harm, potential for more than minimal, widespreadF880Feb 13, 2026

  Based on observation, interview and record review, the facility failed to follow infection control practices related to hand hygiene procedures and wound care procedures for 1 of 1 resident reviewed for pressure ulcers. (Resident 34) In addition, the facility failed to track and complete infection surveillance during a COVID (Coronavirus) outbreak. Findings include: 1.During an interview, on 2/10/2026 at 11:26 A.M., a resident representative indicated Resident 34 had a pressure ulcer on her coccyx. During an observation, on 2/12/2026 at 12:25 P.M., Resident 34 was observed receiving wound care for the wound on her coccyx. Certified Nursing Assistant (CNA) 14 and the IP (Infection Prevention) nurse were already standing outside Resident 34's room. […]

• No harm, potential for more than minimal, widespreadF812Dec 22, 2023

  Based on observation, interview, and record review, the facility failed to store and serve food under sanitary conditions related to open and undated dry goods in 1 of 1 kitchen and touching the eating surface of salad bowls with bare hands in 2 of 2 dining halls observed. This had the potential to affect all 57 residents who resided in the facility and received food from these dietary areas. Findings include: 1. On 12/18/2023 at 9:45 A.M., the following was observed on the initial kitchen tour with the Director of Nursing (DON): a. A spice cart had opened and undated onion powder, paprika, rosemary, and basil. b. […]