Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pilgrim Manor during CMS and state inspections, most recent first.
A resident with multiple medical conditions and intact cognition reported that a nurse aide responded to a call light with a disrespectful comment, telling the resident to get off their 'lazy butt' and go to the bathroom, and further compared the resident to her grandmother. The incident was confirmed by facility documentation and staff interviews, and the DON acknowledged the failure to provide respectful and dignified care.
A resident with severe cognitive impairment and total care needs was hospitalized after a fall and reported to hospital staff that they had been assaulted by facility staff. Upon learning of these allegations from hospital discharge documents, facility leadership did not notify the state agency, relying instead on the hospital's mandated reporter submission, which was contrary to facility policy requiring immediate reporting of abuse allegations.
A resident with severe cognitive impairment and total dependence on staff reported to hospital staff that they had been assaulted or mistreated by facility staff. Although this allegation was documented in hospital records and communicated to the facility, the facility did not initiate a formal investigation as required by policy, instead only updating the care plan to require two staff for all care.
A resident with anxiety, depression, and a rib fracture reported that a nurse aide made disrespectful comments during care. Although the incident was investigated and documented by nursing and social work staff, the facility failed to revise the resident's care plan to include interventions addressing the verbal abuse, as required by policy.
A resident with severe cognitive impairment and multiple health issues, including blindness and a history of TIA, fell and sustained a head injury due to inadequate supervision during incontinent care. The resident, who was on a blood thinner, was left unattended by a nursing assistant, resulting in a fall from the bed. The facility failed to ensure proper supervision and did not conduct a post-fall assessment to verify if safety interventions were in place.
The facility failed to include necessary interventions in the Baseline Care Plans for two residents, leading to deficiencies in care. A resident with a history of falls and a fracture did not have fall prevention measures in their care plan, resulting in a fall and head injury. Another resident admitted with a pressure ulcer lacked a care plan for wound management and pressure relief. The facility did not adhere to its policy of developing a baseline care plan within 48 hours of admission.
A resident with a history of dementia and other conditions fell and sustained a head injury, but the facility failed to conduct the required neurological and fall assessments as per policy. Despite the resident's known fall risk, the necessary checks were not documented before the resident was transferred to the hospital.
A resident with hypothyroidism received an incorrect dosage of Synthroid due to a transcription error in the physician's orders. The resident was supposed to receive 62.5 mcg but was given 125 mcg instead. This error was discovered after lab results showed low blood levels, indicating a dosage issue. The facility failed to provide a policy when requested.
A facility failed to provide proper pressure ulcer care for a resident with a community-acquired ulcer. The resident's wound was not assessed or measured upon admission, contrary to facility policy, and the low air loss mattress was not set correctly for the resident's weight. The wound was only evaluated a week later by a wound physician.
A resident with respiratory issues was left without oxygen during an outing due to improper administration by unauthorized staff. The resident, who required 6L of oxygen, was provided only one portable tank instead of the usual two, leading to a temporary lack of oxygen. The facility's policy states that only nurses should administer oxygen, which was not followed in this instance.
Failure to Treat Resident with Respect and Dignity
Penalty
Summary
A resident with diagnoses including anxiety, depression, rib fracture, and hypertension, who was cognitively intact and required moderate assistance with activities of daily living, reported being treated in a disrespectful and undignified manner by a nurse aide. The incident occurred when the resident, after using a bedpan, activated the call light for assistance. Upon responding, the nurse aide made a derogatory comment, telling the resident to get off their 'lazy butt' and go to the bathroom. When the resident expressed offense, the aide replied that she spoke to her grandmother in the same way, to which the resident clarified that she was not her grandmother but a resident. The aide completed the care without further incident and left the room. The resident reported the incident to another nurse aide but initially did not want to escalate the matter. Documentation from nursing and social work staff confirmed the resident's account of the aide's rude behavior. The Director of Nursing acknowledged that the aide did not treat the resident with respect and dignity, which is contrary to the facility's policy requiring all employees to treat residents with kindness, respect, and dignity.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the state agency after a resident with severe cognitive impairment, multiple comorbidities, and total dependence on staff for activities of daily living was hospitalized following an unwitnessed fall. During the hospital stay, the resident reported to hospital staff that they had been assaulted or mistreated by facility staff. This information was documented in the hospital records and communicated to the facility upon the resident's re-admission. The facility's social worker and nursing staff became aware of the resident's allegations through the hospital discharge documents. Despite being made aware of the abuse allegation, the Director of Nursing and Administrator did not notify the state agency, citing that the hospital had already completed a mandated reporter form and notified the Department of Public Health. Facility policy required that all alleged violations involving abuse be reported immediately, but the facility did not fulfill this obligation, resulting in a failure to timely report the suspected abuse as required.
Failure to Investigate Abuse Allegation Reported by Hospital
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into an allegation of abuse involving a resident with severe cognitive impairment, multiple comorbidities, and total dependence on staff for activities of daily living. The resident, who had a history of being combative and refusing care, was hospitalized following an unwitnessed fall. During the hospital stay, the resident reported to hospital staff that they had been assaulted or mistreated by facility staff. This information was documented in the hospital records and communicated to the facility upon the resident's return. Despite the documentation of the abuse allegation in the hospital records and the facility's own policy requiring thorough investigation of all abuse allegations, the facility did not initiate an investigation. Interviews with the social worker, DON, and administrator confirmed that they became aware of the allegation through hospital discharge documents but did not proceed with a formal investigation, as they believed a lack of verbal communication from the resident or family did not necessitate further action. The facility instead updated the resident's care plan to require two staff members for all care, but did not contact the resident's power of attorney or follow the policy for investigating abuse allegations.
Failure to Update Care Plan After Allegation of Verbal Abuse
Penalty
Summary
A deficiency occurred when the facility failed to revise and implement a comprehensive care plan with measurable interventions and timetables following an allegation of staff-to-resident verbal abuse. The resident involved had diagnoses including anxiety, depression, a rib fracture, and hypertension, and was assessed as having intact cognition but required moderate assistance with activities of daily living. The resident reported that a nurse aide made disrespectful and rude comments during care, which was subsequently reported to another staff member and documented by nursing and social work staff. The facility conducted an investigation, but the care plan for the resident was not updated to reflect the incident or to include new interventions addressing the negative interaction. Review of the clinical record and interviews confirmed that, despite the incident and subsequent investigation, there was no documentation of care plan revisions or implementation of specific interventions to address the resident's experience of verbal abuse. The Director of Nursing acknowledged that a comprehensive care plan should have been developed in response to the allegation, but was unable to provide evidence that this had occurred. Facility policy requires ongoing assessment and care plan updates as resident conditions and information change, but this process was not followed in this case.
Resident Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to appropriately supervise a resident, resulting in a fall with a major injury. Resident #304, who had diagnoses including dementia, anxiety, a history of transient cerebral ischemic attack, atrial fibrillation, and blindness, was severely cognitively impaired and required extensive assistance for bed mobility, transfers, and personal hygiene. The resident was at risk for falls and required assistance with activities of daily living. Despite these needs, the resident was left unattended by NA #1 during incontinent care, leading to a fall from the bed and a head injury. The incident occurred when NA #1 left Resident #304 on their side, unsecured, to obtain water from the bathroom, during which time the resident verbalized sliding and subsequently fell. The resident sustained a head laceration, was bleeding, and complained of back pain. The resident was on Eliquis, a blood thinner, which increased the risk of bleeding. The resident was transferred to the emergency room, where they received treatment for a 2-centimeter laceration and underwent CT scans. Upon return from the hospital, the resident had staples placed in the head and a hematoma was noted. The facility's documentation revealed that NA #1 was educated to have supplies ready and not to leave residents unattended. However, the care plan was not updated to reflect the need for two staff members during care until after the incident. Additionally, there was no post-fall assessment conducted to determine if the fall mat was in place, and the facility failed to provide a policy for accidents and resident supervision and safety. The physical therapist noted that the resident required hands-on assistance and should not have been left alone during care.
Deficiencies in Baseline Care Plans for Fall Prevention and Pressure Ulcer Management
Penalty
Summary
The facility failed to include necessary interventions in the Resident Baseline Care Plan for two residents, leading to deficiencies in care. Resident #454, who was admitted with a history of falls and a displaced fracture, did not have fall prevention interventions included in their care plan. Despite being identified as a fall risk with weight-bearing restrictions, the care plan lacked specific measures to prevent falls. This oversight resulted in the resident experiencing a fall, sustaining a head laceration, and requiring hospital evaluation. The Director of Nursing Services acknowledged the lapse in completing the care plan within the required 48 hours and the absence of fall prevention strategies. Similarly, Resident #554, admitted with an unstageable pressure ulcer, did not have a baseline care plan addressing wound care or the use of a pressure-relieving mattress. The care card was blank, and the necessary directives for wound management were not included. The MDS Coordinator, who was new to the role, admitted the care plan was missed and was responsible for initiating and reviewing care plans. The facility's policy mandates the development of a baseline care plan within 48 hours of admission to address immediate health and safety needs, which was not adhered to in these cases.
Failure to Conduct Neurological and Fall Assessments
Penalty
Summary
The facility failed to assess a resident's neurological status and complete a fall assessment following a fall with a head injury, as per the facility's policy. The resident, who had a history of dementia, anxiety, transient cerebral ischemic attack (TIA), atrial fibrillation, and blindness, was identified as being at risk for falls and required extensive assistance with activities of daily living. Despite these known risks, after the resident fell and sustained a head injury, the facility did not perform the required neurological checks or fall assessment before transferring the resident to the hospital. The facility's policies required that neurological assessments be conducted following any fall or accident involving head trauma, including checking vital signs, pupil reaction, motor ability, and using the Glasgow Coma Scale. However, the documentation lacked evidence of these assessments being completed. Interviews with the RN Supervisor and the Director of Nursing Services confirmed that the assessments were not conducted, and the RN Supervisor was unable to explain the absence of the required documentation.
Medication Transcription Error Leads to Incorrect Synthroid Dosage
Penalty
Summary
The facility failed to correctly transcribe and administer the physician's orders for Synthroid medication for a resident diagnosed with hypothyroidism, metabolic encephalopathy, and vascular dementia. The resident, who was moderately cognitively impaired and required assistance with daily activities, was supposed to receive Synthroid 62.5 mcg via PEG tube daily. However, due to a transcription error, the resident received a full dose of 125 mcg instead of the intended half dose. This error was identified after the resident's laboratory results showed abnormally low blood levels, indicating a potential issue with the medication dosage. The error originated from a miscommunication and incorrect transcription of the physician's orders, which directed the administration of 125 mcg of Synthroid with the instruction to give only half a tablet. The Medication Administration Records (MAR) initially reflected the correct dosage but were later altered, omitting the instruction to administer only half a tablet. This oversight continued until the medication was discontinued in November 2022. The facility's failure to provide a policy upon request further highlights the lack of proper documentation and adherence to medication administration protocols.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident with a community-acquired pressure ulcer. The resident, who was admitted with an unstageable pressure ulcer on the coccyx, did not receive a proper wound assessment or measurement upon admission, as required by the facility's policy. Despite being aware of the wound prior to admission, the facility did not document the wound in the Nursing Admission Evaluation or in the nursing progress notes on the day of admission. It was not until a week later, during a visit with a wound physician, that the wound was evaluated and measured. Additionally, the facility did not ensure that the low air loss mattress was set at the appropriate setting for the resident's weight, which is crucial for pressure ulcer prevention. The lack of documentation and assessment of the wound upon admission, along with the improper mattress setting, contributed to the facility's failure to provide adequate pressure ulcer care and prevention for the resident.
Failure in Oxygen Therapy Administration
Penalty
Summary
The facility failed to provide oxygen therapy consistent with professional standards of practice for a resident diagnosed with chronic obstructive pulmonary disease, acute respiratory failure, and shortness of breath. A physician's order directed the administration of oxygen at 6 liters via nasal cannula. However, during an outing, the resident's portable oxygen tank was noted to be empty, and the resident was without oxygen for approximately 2 minutes, resulting in the resident feeling shaky. The resident typically required two portable oxygen tanks for outings, but only one was provided. The incident occurred because the Recreation Director, who was not authorized to administer oxygen, applied and set the portable oxygen for the resident, unaware that two tanks were needed. The LPN, who was responsible for the resident's care, did not ensure the resident left with the appropriate amount of oxygen. The Director of Nursing Services later confirmed that only nurses are allowed to administer and set oxygen, indicating a lapse in following the facility's policy for oxygen administration.
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What surveyors actually found near you
We read the 907 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cromwell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Cromwell | 0.6 mi | ★★★★★ | 0 | 0 |
| Portland Care & Rehab Centre, Inc | 1.9 mi | ★★★★★ | 19 | 0 |
| Apple Rehab Cromwell | 2.8 mi | ★★★★★ | 20 | 0 |
| Water's Edge Center For Health & Rehab | 3.2 mi | ★★★★★ | 15 | 0 |
| Wadsworth Glen Health Care And Rehabilitation Cent | 3.4 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.