Pilgrim Rehabilitation & Skilled Nursing Center

In the surveyor’s words

From the most serious findings on record at Pilgrim Rehabilitation & Skilled Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF686Jan 5, 2023

  Based on observation, record review and interview, the facility failed to ensure that staff identified and addressed the deterioration of a shearing wound consistent with professional standards of practice to promote wound healing for 1 Resident (#234) out of a total of 25 sampled Residents. Specifically, Resident #234's shearing wound deteriorated which resulted in the development of an unstageable pressure ulcer. Findings include: Review of the facility's Skin Integrity Management policy, revised March 16, 2022, indicated: *Based on a comprehensive assessment, the facility will ensure that the resident receives the necessary treatment and services consistent with professional standards of practice to prevent the occurrence of pressure ulcers, promote healing of all wounds, prevent… […]

• Actual harm, isolatedF760Aug 23, 2022

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Hospital Discharge Summary included physician's orders for Potassium Chloride (mineral supplement) 40 millequivalents (meq) twice daily, the Facility failed to ensure he/she was free from a significant medication error, when due to a transcription error upon admission by nursing, Resident #1 was only administered Potassium Chloride 20 meq twice daily (half the amount ordered), as a result his/her Potassium level became critically low, he/she was transferred to the Hospital Emergency Department, diagnosed with [CONDITION(S)] (low potassium level), required administration of intravenous potassium supplements, and was admitted . […]

• Actual harm, isolatedF656Jan 12, 2021

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), was who assessed for the use of bilateral upper quarter side rails on his/her bed as enablers, had a physician's orders [REDACTED]. On 12/28/20, Certified Nurse Aide (CNA) #1, assisted Resident #1 with personal hygiene, Resident #1 attempted to roll onto his/her right side, however, there were no side rails installed on either side of the bed, Resident #1 rolled out of bed onto the floor, and sustained a right distal femur fracture, which required surgical intervention to repair. […]

• Actual harm, isolatedF689Jan 12, 2021

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), was who assessed for the appropriate use of bilateral upper quarter side rails, had a physician's orders [REDACTED]. On 12/28/20, Certified Nurse Aide (CNA) #1 assisted Resident #1 who was in bed, with personal hygiene, however there were no bilateral upper quarter side rails in place on the bed for Resident #1 to hold on to, as Resident #1 attempted to roll onto his/her right side in bed, he/she rolled off the bed onto the floor, and sustained a right distal femur fracture which required surgical intervention to repair. […]

• No harm, potential for more than minimal, widespreadF909Jan 30, 2025

  Based on observation, record review and interview, the facility failed to regularly inspect bed frames and mattress spacing to identify areas of potential entrapment. Specifically, the facility failed to regularly inspect and document findings regarding the seven zones of bed entrapment of Residents' beds for potential areas of entrapment as evidenced by a bed bolster (an object used to fill gaps between the mattress and headboard/footboard of a bed) that did not fit properly. […]