Pilgrim Place Health Services Center

In the surveyor’s words

From the most serious findings on record at Pilgrim Place Health Services Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Nov 19, 2021

  Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of Corona Virus 19 (COVID-19, a mild to severe respiratory illness that spread from person to person) by failing to conduct a COVID-19 Real Time-Polymerase Chain Reaction test (RT-PCR test-a diagnostic test used to detect [CONDITION(S)]-CoV-2, the virus that causes COVID-19) for 42 of 42 residents in the facility after one healthcare worker (Dietary Staff 1 [DS 1]) had a positive test result for COVID-19 reported to the facility on [DATE], in accordance to the local Public Health guidelines and facility's policy and procedures. This deficient practice had the potential to result in the transmission of COVID 19 to the residents, other staff, and visitors. […]

• No harm, potential for more than minimal, patternF578Dec 5, 2025

  Based on interview and record review, the facility failed to ensure three of four sampled residents' (Resident 11, Resident 59 and Resident 73) had consistent and accurate records and information regarding Advance Directives (AD - legal document indicating resident preference on end-of-life treatment decisions) filed in the resident's medical records (chart).This failure had the potential to cause confusion among staff and Resident 11, Resident 59 and Resident 73 to receive inappropriate or medically unnecessary care and/or treatment or services regarding life-sustaining treatment.Findings:a. […]

• No harm, potential for more than minimal, patternF605Dec 5, 2025

  Based on interview and record review, the facility failed to ensure that physician orders for PRN (on as-needed basis) psychotropic drugs (a substance that affect the mind, emotions, and behavior) for Lorazepam (a commonly used drug to reduce anxiety and agitation) included the required 14-day stop-date for two of five sampled residents (Residents 98 and 101).This failure had the potential to result in unnecessary or prolonged exposure to psychotropic medications, risk of adverse drug reactions, oversedation, increased fall risk, and diminished ability to evaluate the resident's ongoing need for the medication.Findings:During a review of Resident 101's admission Record (AR), the AR indicated the facility admitted Resident 101 on 6/28/2024, and re-admitted the resident on 11/19/2025, with… […]

• No harm, potential for more than minimal, patternF686Dec 5, 2025

  Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services were provided, for two of two sampled residents (Resident 54 and Resident 87), who were at risk for skin breakdown and pressure injuries (PI, localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence or related to medical devices) to prevent skin breakdown. The facility failed to:A. Ensure Resident 54's low air loss mattress (LALM, air-filled mattress used to relieve pressure) was replaced after it was removed due to an air leak.B. […]

• No harm, potential for more than minimal, patternF689Dec 5, 2025

  Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 7 and Resident 36), were provided an environment free of accident (refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident) hazards by failing to, A. Ensure Resident 7's bed was in a low position required to prevent a fall (refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force). B. […]