Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 dementia, severe cognitive impairment, and documented wandering and exit-seeking behaviors was assessed as an elopement risk and care planned for diversion and reorientation interventions, but staff did not consistently implement effective preventative measures. Progress notes described ongoing confusion, sundowning, anxiety about family, and prior wandering episodes, including the resident being found outside on a previous occasion. On the day of the incident, the resident repeatedly attempted to exit through different doors and was redirected, yet was later able to self-propel in a wheelchair through an exit door that required manual locking and leave the building unattended for several minutes. At the time, the resident was not wearing a Wander Guard, and the QMA on duty reported being unaware of the resident’s elopement risk status or any requirement for 15-minute checks.
A resident with a colostomy and aspirin therapy had blood and blood clots found in the ostomy bag during ostomy care, but the nurse did not promptly see the message, and the finding was not documented or reported to the provider or POA. The resident later developed severe abdominal pain, no ostomy output, and was sent to the ED with an acute GI bleed and anemia requiring PRBC transfusion and transfer to a larger hospital.
Food was not prepared and served under sanitary conditions when kitchen staff were observed in the kitchen without required hairnets and hall tray foods were found below required hot holding temperatures, including ham and scalloped potatoes at 110 degrees F and carrots at 111 degrees F, while cold items were also out of range. The Dietary Mgr stated food stayed on the steam table until plated or placed on meal trays, and facility policy required hair nets or caps in the kitchen and hot foods to be maintained at or above 135 degrees F.
A facility failed to follow infection control practices during wound care for a resident with an open coccyx pressure ulcer when a CNA donned gloves without hand hygiene and an IP nurse reused flipped gauze pads while cleansing the wound. The facility also did not complete required infection surveillance documentation during a COVID outbreak, despite its policy addressing infection prevention measures and identifying and managing ill residents and staff.
The facility failed to obtain informed consent for psychotropic medication use for multiple residents. Residents with diagnoses including depression, dementia, anxiety, schizoaffective disorder, PTSD, psychotic disorder, and bipolar disorder were receiving antidepressants, antianxiety meds, antipsychotics, and a hypnotic, but consent notifications and signatures were not obtained until after the survey team requested the documentation.
An LPN signed a resident’s meds as administered before giving them, then handed a souffle cup of oral meds and two inhalers to another LPN, who administered them without verifying them against the MAR. The resident, who was cognitively intact and receiving opioid pain meds, reported delays and being told to wait until after breakfast for her morning and pain medications. A QMA stated meds should not be signed as given before administration and should not be administered by another staff member after being prepared by someone else.
A resident who was cognitively intact and receiving opioid pain meds reported that an LPN was sharp and snippy when she asked about delayed morning meds, including pain medication she had requested earlier. During the interaction, the LPN was argumentative and unkind in the hallway, and another LPN heard the exchange and took over medication administration. The ED stated staff were expected to speak to residents in a kind, respectful, and helpful manner.
A resident with multiple chronic conditions, including HTN, CHF, CKD, DM, and dementia, returned from the ER after treatment for severe HTN. Staff gave scheduled antihypertensives without first consulting the physician despite ER discharge instructions, and the resident later developed hypotension and was difficult to arouse. The record also showed repeated failures to notify the physician or NP for BP and blood sugar readings outside ordered parameters, including very high BP values and multiple low glucose readings tied to insulin orders.
A resident with dementia and severe cognitive impairment had a bed alarm used for safety and fall prevention, but the record lacked documentation of a pre-use safety assessment and did not show resident/family education or consent for the alarm. Staff, including an LPN, UM, and DON, stated they believed bed alarms were not restraints and therefore did not require restraint assessments or related documentation, and the facility could not provide proof that the family had requested or agreed to the alarm.
Failure to implement ordered hand splints for a resident with RA and bilateral hand contractures. OT notes said the splints fit properly, were in good functional order, and should be worn at night, but there was no nursing chart order or documentation that management was aware of the order. The DON stated she should have entered the order for the resident’s bilateral hand splints.
Antibiotic stewardship was not followed when a resident received an antibiotic for a UTI without an adequate assessment to support the treatment. The IP Nurse stated the ordered UA and/or C&S was not completed, McGeer’s criteria were not met, and the physician was not notified that the antibiotic use lacked criteria support.
Walk-in freezer had longstanding ice buildup. During kitchen observation, surveyors found a large ice accumulation between the cooling unit and the upper corner of the freezer, including formations described as the size of a small watermelon and a cantaloupe. The Dietary Mgr said a work order had been submitted weeks earlier, and the Maintenance Dir stated the buildup had been present since he was hired, at least over a year.
A facility failed to follow bowel movement protocols for a resident with Alzheimer's and constipation, leading to an ileus. Despite a care plan and bowel protocol, the facility did not document or assess bowel movements for several days, nor did they administer prescribed medications. Staff interviews revealed non-compliance with the protocol, contributing to the resident's condition.
The facility's kitchen was found to have unsanitary conditions, including improperly stored and dated food items, a malfunctioning sanitation system, and a mini freezer with heavy ice buildup. The Dietary Manager acknowledged these issues, which were not in compliance with the facility's policies on food storage and sanitation.
The facility failed to honor residents' rights to choose where to eat, as three residents reported being unable to receive meals in their rooms unless deemed too ill. Despite being cognitively intact and requiring minimal assistance, residents were encouraged to eat in the dining room, contradicting the facility's policy of allowing self-determination in daily routines.
The facility failed to provide quarterly personal fund statements to two residents, despite their policy requiring it. Both residents, who are cognitively intact, reported not receiving the statements, with one receiving only verbal updates and the other receiving just one statement since admission. The BOM confirmed the lack of a specific schedule for issuing statements and could not provide documentation of compliance with the policy.
A facility failed to conduct a timely self-administration of medication assessment for a resident. The resident was allowed to self-administer medications, with a care plan and physician's order supporting this practice. However, the last assessment was completed several months prior, and no recent assessments were available, contrary to the facility's policy requiring quarterly evaluations.
The facility failed to create comprehensive care plans for three residents with specific medical conditions. A resident with hemiplegia, seizure disorder, GERD, and glaucoma did not have a care plan for these conditions. Another resident with a splint on her wrist and finger lacked a care plan for splint use, and a resident with a pacemaker did not have a care plan for its use and care. The Director of Nursing confirmed the absence of these care plans, which is against the facility's policy requiring comprehensive, person-centered care plans.
A resident with Alzheimer's and physical debility suffered burns from spilled soup due to inadequate supervision and assistance during meals. Despite conflicting staff accounts and a physician's determination of nonthermal wounds, the facility failed to develop a care plan for burn prevention. The resident's cognitive and physical impairments increased the risk of such incidents, highlighting a lapse in implementing safety evaluations and precautions.
The facility failed to properly store and date respiratory equipment for three residents, leading to deficiencies in care. A resident's nebulizer was not stored correctly, and nasal cannula changes were not performed as ordered. Another resident's oxygen tubing was not changed, and the concentrator filter was dusty. A third resident's oxygen tubing lacked a humidification bottle, contrary to orders and policy. Staff interviews confirmed these issues.
A resident with cognitive impairment did not receive prescribed medications for constipation over several days, and the facility failed to document narcotic counts every shift. An LPN confirmed the lack of signatures in the narcotic logbook, and facility policies on medication management were not followed.
The facility failed to ensure proper storage and labeling of medications. Observations revealed loose pills in medication carts, expired glucose test strips, and an opened container of Miralax without an opened date. Staff acknowledged these issues, which were contrary to the facility's policy requiring medication carts to be clean and orderly.
The facility failed to implement enhanced barrier precautions during wound care for a resident with a pressure ulcer, as staff did not wear gowns or face masks despite a physician's order. Additionally, catheter tubing and drainage bags for another resident were improperly stored, with the drainage bag resting on the floor and the tube filled with urine, contrary to facility policy.
A resident with dementia was improperly restrained to a wheelchair using a bed sheet by two staff members, Employees 4 and 5, to prevent him from standing up. The incident was reported but not thoroughly investigated by the facility. The resident was severely cognitively impaired and dependent on a wheelchair for mobility.
A facility failed to report and investigate an alleged abuse incident where a resident was secured to a wheelchair with a sheet by two staff members. The incident was not reported to the State Agency, and the staff involved were not suspended pending investigation, contrary to the facility's abuse prevention policy. The resident, who has dementia and is wheelchair-dependent, was allegedly restrained to prevent falls, but the facility did not conduct a thorough investigation.
A resident was secured to a wheelchair with a bed sheet by two staff members, which was not reported to the State Agency. The incident involved tying the sheet behind the wheelchair, and although reported internally, no immediate action was taken against the staff involved. The resident, who was severely cognitively impaired and dependent on staff, was at risk due to this inappropriate intervention.
A resident was allegedly secured to a wheelchair with a sheet by two staff members, but the facility failed to conduct a thorough investigation. Despite the incident being reported, the involved employees were not suspended as per policy. Discrepancies in staff accounts and lack of proper investigation highlight a deficiency in handling abuse allegations.
A resident with cognitive impairments sustained second-degree burns after spilling hot tea in a facility that failed to monitor beverage temperatures. Staff interviews revealed that the facility did not check hot liquid temperatures before serving, and a hot liquid safety evaluation for the resident was not conducted until after the incident.
Failure to Implement Elopement Precautions Resulting in Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to implement preventative measures for a resident identified as an elopement risk, which resulted in an elopement. The resident had diagnoses including dementia and a pathological hip fracture and was assessed on admission as having severe cognitive impairment, forgetfulness, short attention span, fear/anxiety, and exit-seeking behaviors such as expressing a desire to go home and hovering at exit doors. Documentation showed repeated episodes of confusion, anxiety about his children and other family members, and wandering behaviors, including being found on a different hall from his assigned room and being difficult to redirect. The care plan identified the resident as an elopement/wander risk and included interventions such as distraction with pleasant diversions, structured activities, toileting, walking inside and outside, and reorientation strategies. Progress notes over several days documented ongoing confusion, sundowning behavior, agitation about the perceived need to care for his children, concern about his car, and repeated requests to go home. On one occasion, the resident was observed outside of the facility and described as having chronic and persistent confusion. An elopement risk assessment was completed and a Wander Guard device was reportedly placed in the back pocket of the resident’s wheelchair; however, at the time of the elopement the resident was not wearing a Wander Guard. Staff notes indicated the resident continued to self-propel in his wheelchair up and down various hallways, looking for his daughters, and although he was sometimes easily redirected, his exit-seeking behavior persisted. On the date of the elopement, camera footage showed the resident self-propelling his wheelchair within sight of staff and then down the hallway before exiting the building through a door that required manual locking by staff and was usually locked later in the evening. The resident was outside, unattended, for over four minutes before re-entering the building. Staff statements indicated that shortly before the elopement, the resident had twice attempted to leave through different exit doors, including doors near the dietary department and at the end of his hallway, and had been brought back and redirected. The QMA responsible for the resident at that time reported she was unaware that the resident was an elopement risk or that 15-minute checks were required, and there was no paperwork indicating such checks. Another staff member confirmed the resident was outside in the parking lot and not wearing a Wander Guard when found, and the Executive Director confirmed the exit door used by the resident was not automatically secured and had to be manually locked by staff.
Failure to assess and report blood in colostomy output
Penalty
Summary
The facility failed to assess, document, and notify the provider and the resident’s family after blood and blood clots were found in a resident’s colostomy bag during ostomy care. The resident had diagnoses including colostomy, thrombocytosis, schizophrenia, major depressive disorder, generalized anxiety disorder, and chronic kidney disease, and was receiving aspirin therapy. The resident’s care plan identified the colostomy and the risk for bleeding, with staff instructed to observe for, document, and report signs of anticoagulant complications, including dark or bright red blood in stools. During second shift, a staff member performing colostomy care observed blood and blood clots in the colostomy bag and took a picture to send to the assigned nurse. The assigned nurse did not see the message until after leaving the facility, then contacted the third shift nurse, who passed the information to the first shift nurse the next morning. None of the involved employees documented the blood and blood clots in the medical record, and there was no documentation that the resident’s condition was assessed by a nurse or that the provider or the resident’s POA/family was notified of the change. The resident later continued to complain of severe abdominal pain, had no gas or stool output for over 30 hours, and had hypoactive bowel sounds. The provider was eventually notified and the resident was sent to the ED, where she was found to have a hemoglobin of 6.5 and hematocrit of 20.1, required two units of packed red blood cells, and was diagnosed with an acute GI bleed causing anemia, with transfer to a larger hospital required.
Food Temperature and Kitchen Sanitation Deficiency
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions related to staff hygiene in the kitchen and food temperatures of hall trays for 1 of 1 kitchen areas observed. During an interview, the Dietary Manager stated that food remained on the steam table until it was plated or placed on resident meal trays. During an observation of the last hall tray, the Dietary Manager recorded temperatures of ham and scalloped potatoes at 110 degrees Fahrenheit, carrots at 111 degrees Fahrenheit, chocolate milk at 46 degrees Fahrenheit, and fruit cocktail at 60 degrees Fahrenheit. Immediately after the temperature checks, the Dietary Manager stated the food should have been hotter than the recorded temperatures and noted the facility had recently ordered new plate warmers. During a kitchen observation, two maintenance staff were standing in the kitchen without hairnets while the kitchen door was open. One maintenance staff member was wearing a knit cap and kneeling on the floor, and the other was holding the kitchen door open. The Dietary Manager stated that hair nets were required for all staff entering the kitchen. The facility policy titled Employee Sanitary Practices stated that hair nets or caps covering all hair must be worn at all times and that the cap must be designated for kitchen use only. The facility policy titled Temperatures stated that foods sent to the units for distribution must be transported and delivered to maintain temperatures at or below 41 degrees F for cold foods and at or above 135 degrees F for hot foods and hot beverages.
Infection Control Failures During Wound Care and COVID Surveillance
Penalty
Summary
The facility failed to follow infection control practices during wound care for a resident with an open coccyx pressure ulcer. The resident had diagnoses including acute on chronic systolic heart failure, diabetes mellitus, dementia, peripheral vascular disease, morbid obesity, hypertensive heart disease, acute on chronic respiratory failure, depression, paranoid schizophrenia, hypothyroidism, anxiety, and agoraphobia with panic disorder. The resident’s most recent MDS indicated she was cognitively intact. During wound care, a CNA entered the room and put on gloves without performing hand hygiene. The resident was repositioned, her slightly wet incontinence brief was removed, and the open coccyx wound, approximately the size of a quarter, was observed without a dressing in place. The IP nurse then cleansed the wound using moistened gauze pads and was observed to flip each used gauze pad over and reuse it to continue cleansing the wound in the same direction. The facility’s policy indicated hand hygiene is performed before and after resident contact and before aseptic tasks, and the dressing policy indicated clean gauze should be used for each cleansing stroke. The facility also failed to track and complete infection surveillance during a COVID outbreak. The IP nurse stated the facility experienced a COVID outbreak in January 2026, but the infection had not been tracked as required and there was no infection surveillance documentation completed for the outbreak. The facility’s COVID infection control and prevention policy stated that infection prevention measures are incorporated into the infection prevention and control plan and include identifying and managing ill residents and staff.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medication administration for 5 of 5 residents reviewed for unnecessary medications. Resident 5 had diagnoses of anxiety disorder and depression, was cognitively intact, and was receiving desvenlafaxine for depression and buspirone for anxiety. Resident 57 had depression and dementia, was not able to be interviewed due to cognitive status, and was receiving Lexapro for depression. In interview, the Social Service Director stated that all notifications and signatures for medication consents had not been obtained until after the survey team requested the documentation. Resident B had diagnoses including dementia, schizoaffective disorder, PTSD, psychotic disorder, generalized anxiety, and bipolar disorder, and was receiving multiple psychotropic medications including Klonopin, Zyprexa, ramelteon, and buspirone. Resident B stated that the Social Service Director had just left the room after obtaining informed consent for psychotropic medication use, and the Social Service Director confirmed that the resident had just signed the form. Resident H had diagnoses including dementia, major depressive disorder, and mood adjustment disorder, and was receiving Cymbalta for depression; the record review identified the same pattern of missing consent documentation for psychotropic medication use.
Medication Administration Errors and Improper Hand-Off of Prepared Medications
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when nursing staff failed to follow standard medication administration procedures for Resident L. Resident L was admitted with diagnoses including left femur fracture, diabetes mellitus type 2, and anxiety disorder, and her admission MDS indicated she was cognitively intact and received opioid medications for pain. During an interview, Resident L stated an LPN was sharp and snippy when she requested her morning medications and pain medication, and that the medications had not yet been given even though she had requested the pain medication two hours earlier. She reported being told she needed to wait until after breakfast for her medications. A review of the January MAR showed all medications, including the PRN pain medication, had already been signed as administered before Resident L reported the concern to surveyors. During observation, the LPN was heard telling Resident L that she had pulled the medications for administration before the complaint to surveyors. The LPN initially stated she had not signed the medications as given before administration, then said she must have signed them as already given when questioned about the MAR. The LPN then handed a souffle cup of oral medications and two inhalers to another LPN, who administered them to Resident L without verifying the medications against the MAR before giving them. The QMA stated medications should not be signed as given prior to administration and that another nursing staff should never administer medications prepared by someone else.
Resident Was Not Treated With Dignity During Medication Concern
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect when she raised concerns about medication administration. Resident L, who was cognitively intact and had diagnoses including left femur fracture, type 2 diabetes mellitus, and an anxiety disorder, stated that an LPN had been sharp and snippy with her after she asked about not receiving her morning medications, including pain medication she had requested two hours earlier. Resident L reported that she was told to wait for her medications until after breakfast. During observation, Resident L returned to the unit and the LPN stated that she had pulled the medications before Resident L complained to surveyors, then continued to speak in an argumentative and unkind manner. Resident L responded that the LPN was being snarky. Another LPN heard the interaction in the hallway, described Resident L as feeling the LPN had been snarky, and removed the prepared medications from the first LPN so they could be administered by the second LPN. The Executive Director stated staff were expected to speak to residents in a kind, respectful, and helpful manner and that the LPN should not have been argumentative.
Failure to Follow Medication and Notification Orders
Penalty
Summary
The facility failed to consult the physician before administering scheduled antihypertensive medications after a resident returned from the emergency room with discharge instructions that identified Metoprolol tartrate and Torsemide as medications to ask the doctor about. The resident had multiple diagnoses including resistant hypertension, chronic diastolic congestive heart failure, atrial fibrillation, chronic kidney disease, hypotension, diabetes mellitus, and dementia, and was moderately cognitively impaired. After the resident returned from the emergency room, the nurse administered the routine morning doses of Torsemide and Metoprolol without documented physician consultation, and later that morning the resident’s blood pressure dropped to 88/44 mmHg and the resident was difficult to arouse to a sternal rub. The record also showed that the resident was sent back to the emergency room after family concerns about cognitive status, and the hospitalist documented that routine blood pressure medications had continued with subsequent hypotension. The hospitalist further documented that the resident met clinical criteria for sepsis, which was precipitated by medication-induced hypotension and resulted in acute kidney injury in the setting of chronic kidney disease. A nurse practitioner later documented that after receiving Labetalol and Hydralazine in the hospital, the resident returned to the facility, received routine morning medications, became somnolent, and was sent back to the emergency room and diagnosed with sepsis. In a separate review of the same resident’s record, the facility did not notify the physician when blood pressure readings were outside ordered parameters. A physician order required notification for blood pressure greater than 160/80 mmHg, but recorded readings of 220/100 mmHg and 192/86 mmHg were not reported. The record also showed multiple blood sugar readings that were below the thresholds in the resident’s insulin orders and were not reported as required. One order required holding Humalog if blood sugar was below 200 mg/dL and notifying the physician, and another later order required holding Humalog if the resident did not eat and notifying the nurse practitioner if blood sugar was below 150 mg/dL; several blood sugar values below those limits were documented without notification. Interviews with staff confirmed that vital signs outside ordered parameters should have resulted in physician or nurse practitioner notification.
Bed Alarm Used Without Required Assessment or Documented Consent
Penalty
Summary
The facility failed to provide timely assessments related to the safe and appropriate use of a bed alarm and failed to document resident/family education and consent for the bed alarm for one resident. Resident 30 had diagnoses including dementia, anxiety disorder, depression, hypertension, and dysphagia, and a quarterly MDS dated 12/11/2025 indicated severely impaired cognition, dependence on staff for all transfers, and daily use of a bed alarm. The resident’s current physician’s order required the bed alarm placement and function to be checked every shift, and the care plan identified the bed alarm as an intervention for enhanced safety and fall prevention. During observation, the bed alarm pad was seen on the empty bed with the cord plugged into an alarm near the bed. The resident was not observed in bed during multiple random observations over several days. The record lacked documentation showing the resident had been assessed for safety related to bed alarm use before the alarm was applied, and a physical restraint evaluation started on 6/20/2025 had not been completed. Completed restraint evaluations on 8/21/2025 and 10/21/2025 indicated restraints were not recommended. Staff interviews showed the LPN and UM believed bed and chair alarms were not restraints and did not require restraint assessments, and the DON stated staff had been told bed alarms were not restraints and did not need quarterly evaluations, resident/family education, or documented family consent. The UM and DON were unable to provide documentation that the family had requested the bed alarm, had been educated about it, or had agreed to its use.
Failure to Implement Ordered Hand Splints
Penalty
Summary
The facility failed to ensure hand splints to prevent bilateral hand contractures were implemented for one resident with rheumatoid arthritis and contractures of both hands. The resident’s clinical record showed diagnoses including rheumatoid arthritis and contracture of the left and right hand, and the care plan identified self-care deficits related to joint pain, decreased mobility, and rheumatoid arthritis, with interventions including therapy evaluation and treatment per medical director orders and the treatment plan of care. Occupational therapy notes stated that the resident’s current hand splints were appropriate, fit properly, and should continue to be worn at night, and a later note indicated the splints were in good functional order and appropriate for use. However, there was no order for the splints in the nursing charting and no documentation that nursing management staff were made aware of the order. The DON acknowledged that she should have entered the order for bilateral hand splints at night for the resident.
Antibiotic Stewardship Not Supported by Adequate Assessment
Penalty
Summary
The facility failed to ensure its infection control program promoted antibiotic stewardship when a resident was treated with an antibiotic for a urinary tract infection without an adequate assessment completed to support the use of the medication. During interview, the Infection Prevention Nurse stated the resident received an antibiotic on 1/4/2026 for 5 days, while a urinalysis and/or culture and sensitivity had been ordered the same day to verify the infection but had not been completed as ordered. The Infection Prevention Nurse also stated the facility was to use McGeer’s criteria to determine the need for an antibiotic, but the resident’s antibiotic use had not met those criteria and the physician had not been notified of the lack of criteria to support the treatment.
Walk-in freezer had longstanding ice buildup
Penalty
Summary
Keep all essential equipment working safely was not met when the facility failed to ensure the walk-in freezer was in working order for 1 of 1 kitchen reviewed. During observation of the kitchen on 2/09/2026, the walk-in freezer located directly outside the facility had a large accumulation of ice buildup between the cooling unit and the upper southern corner, including one formation the size and shape of a small watermelon and another the size of a cantaloupe shaped like an uppercase L. The Dietary Manager stated she had submitted a work order weeks earlier to have the ice buildup removed and said the Maintenance Director told her the freezer could not be fixed until it was thawed out. The Maintenance Director later stated the ice buildup had been present since he was hired, which had been at least over a year. The Administrator provided the facility policy titled Malfunctions and Repairs, dated 7/2023, which stated that malfunctions and repairs are reported to the food service manager and maintenance department and that outside help or parts purchases must be approved per facility policy.
Failure to Follow Bowel Movement Protocols Leads to Resident's Ileus
Penalty
Summary
The facility failed to adhere to bowel movement protocols for Resident K, who was diagnosed with Alzheimer's disease and constipation. The resident's care plan, initiated in July 2024, included interventions to prevent constipation, such as administering medications as ordered and monitoring bowel movements. However, the August 2024 physician's orders did not include any as-needed medications for bowel movements, and the facility did not document any bowel movements for Resident K from August 17 to August 18, and again from August 20 to August 25, 2024. Despite the facility's bowel protocol requiring action after two days without a bowel movement, no assessments or notifications to the physician were made during these periods. On August 26, 2024, the resident's family expressed concern about abdominal swelling, leading to an abdominal x-ray that revealed an ileus. New medication orders were given, but the facility failed to administer these medications from August 26 to August 29, 2024. The resident continued to have infrequent bowel movements, with documentation showing only small bowel movements on August 26 and August 28, 2024. The facility's failure to follow the bowel protocol and administer prescribed medications contributed to the resident's condition. Interviews with facility staff revealed that the bowel movement regimen was not followed, as the protocol required specific actions after two, three, four, and five days without a bowel movement. The facility's policy outlined the need for documentation and assessment of bowel movements each shift, with evening shift nurses responsible for responding according to the protocol. Despite these guidelines, the facility did not take appropriate action, resulting in the resident's ileus and ongoing bowel issues.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure food was stored and prepared in a sanitary manner, as observed during a survey of the kitchen. Several food items, including cream base soup, biscuit gravy mix, coconut, pasta, and spices, were found opened without proper sealing or documentation of open dates. Additionally, chopped garlic was improperly stored on a shelf instead of being refrigerated. The mini freezer was observed to have heavy ice buildup, and the sanitation bucket at the prep counter and dishwashing machine was found to have zero concentration of sanitation chemicals, indicating a malfunction in the automated sanitation disbursement system. The Dietary Manager acknowledged these issues, noting that the opened bags of food should have been sealed and dated, and the garlic should have been refrigerated. The sanitation solution was not flowing through the tubing, and it was unclear how long this had been the case. The mini freezer was not on a defrosting schedule, although it was typically unplugged monthly to defrost. The facility's policies on dietary stock procedures, freezer cleaning, and cleaning cloths and buckets were not adhered to, contributing to the unsanitary conditions observed in the kitchen.
Failure to Honor Residents' Dining Preferences
Penalty
Summary
The facility failed to honor the residents' rights to choose where to eat, as evidenced by interviews and record reviews for three residents. Resident C, who was cognitively intact and required only set-up assistance for eating, reported that she was not allowed to eat in her room unless she was too sick to go to the dining room. Staff interviews confirmed that residents on the North Hall were encouraged to eat in the dining room and would not receive meals in their rooms unless deemed too ill. This practice was in contradiction to the facility's policy, which allowed residents to choose their daily routines, including where to eat. Resident N, also cognitively intact, indicated that she had to keep food in her room because staff would not bring meals to her room if she chose not to go to the dining room. Similarly, Resident D, who was independent in eating, reported having to go to the dining room even when she did not feel well, as staff would not provide meals in her room. The Dietary Manager was unaware of any residents receiving room trays, further highlighting the facility's failure to adhere to its policy of allowing residents to exercise their rights to self-determination and participation in their daily routines.
Failure to Provide Quarterly Personal Fund Statements
Penalty
Summary
The facility failed to provide quarterly statements for personal funds to two residents, Resident 5 and Resident E, as required by their policy. Resident 5, who is cognitively intact and has diagnoses including dementia with psychotic disturbance and bipolar disorder, reported not receiving quarterly statements for her personal funds account. Instead, she was verbally informed of her account balance by the Business Office Manager (BOM) when she inquired. Similarly, Resident E, who is also cognitively intact and has diagnoses including heart failure and atrial fibrillation, indicated he had only received one quarterly statement since his admission to the facility. The BOM confirmed that residents received personal fund statements upon request or when they withdrew money, but there was no specific schedule for providing these statements. The BOM was unable to provide documentation that the residents or their representatives had received the required quarterly statements. The facility's policy, titled 'Accounting and Records,' mandates that individual financial records be available through quarterly statements and upon request. This lack of adherence to the policy resulted in the deficiency noted by the surveyors.
Failure to Conduct Timely Medication Self-Administration Assessment
Penalty
Summary
The facility failed to complete a timely self-administration of medication assessment for Resident N, who was reviewed for self-administration of medications. During an interview, Resident N stated that a nurse left her medications in her room, which she took herself. QMA 16 confirmed that it was acceptable to leave medications in Resident N's room because she was alert and oriented. The resident's care plan, initiated on 7/28/2024, indicated that she requested to administer her own medications, with interventions allowing medications to be left with her except for narcotics. A physician's order from 8/18/2024 permitted medications to be left at the bedside every shift. However, the last Self Administration of Medications Assessment was completed in May 2024, and no more recent assessments were available for August or November, despite the facility's policy requiring quarterly assessments.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents with specific medical conditions. Resident 39, who had diagnoses including hemiplegia, seizure disorder, GERD, and glaucoma, did not have a care plan addressing these conditions despite receiving medications such as clopidogrel, levetiracetam, carbamazepine, pantoprazole, and dorzolamide-timolol. The Director of Nursing confirmed the absence of a care plan for these conditions during an interview. Resident 22, who had a splint on her right wrist and fifth finger, also lacked a care plan for the use of splints, despite recommendations from an Occupational Therapy Evaluation. Similarly, Resident 29, who had a pacemaker, did not have a care plan for its use and care. The Director of Nursing acknowledged the absence of care plans for both the splint and pacemaker during interviews. The facility's policy requires the Interdisciplinary Team to develop comprehensive, person-centered care plans, which was not adhered to in these cases.
Failure to Prevent Burn Incident in Resident with Cognitive Impairment
Penalty
Summary
The facility failed to prevent a burn incident involving a resident, identified as Resident M, who was reviewed for accident hazards. During a routine skin assessment, a nurse discovered blisters on Resident M's bilateral inner legs, which were believed to have resulted from hot soup being spilled on her lap. The incident was reported, and an investigation was initiated. However, there were no witnesses to confirm the exact cause of the burns. Resident M required staff assistance to eat, and her care plan was reviewed and updated following the incident. Witness statements from staff members, including CNAs and LPNs, provided conflicting accounts of the incident. CNA 16 reported that during supper, Resident M had soup in front of her, which was later found missing and allegedly spilled on her lap. CNA 19, who was present, also observed the soup spill and noted redness on Resident M's thigh. LPN 17 and RN 18 confirmed the presence of blisters during their assessments. Despite these observations, the physician determined the wounds to be nonthermal, and the facility's Regional Director of Nursing Services concluded that no further action was needed. Resident M's medical records indicated diagnoses of Alzheimer's disease, contracture of the right hand, and physical debility, with severe cognitive deficiency and a need for maximal assistance with eating. A Hot Liquid Safety Evaluation was conducted, highlighting Resident M's cognitive impairment and physical limitations that increased her risk of burns. Despite these findings, a care plan for burn prevention was not developed. The facility's policy on hot liquid safety emphasized evaluating residents for potential injury risks and implementing precautions, but these measures were not effectively applied in Resident M's case.
Deficiencies in Respiratory Equipment Management
Penalty
Summary
The facility failed to ensure proper storage and dating of respiratory equipment for three residents, leading to deficiencies in respiratory care. For Resident 53, the handheld aerosol nebulizer was repeatedly observed lying on the bedside table without a cover or proper storage, and the nasal cannula was not changed as per physician orders. The resident's care plan indicated a need for oxygen therapy and regular equipment changes, but these were not consistently followed. Interviews with the resident and staff confirmed the lack of proper storage and dating of equipment. Resident 16's oxygen tubing was not changed according to physician orders, and the oxygen concentrator filter was covered with dust on multiple occasions. The care plan required regular monitoring and equipment changes, which were not adhered to. Similarly, Resident F's oxygen tubing was connected directly to the machine without a humidification water bottle, contrary to physician orders and facility policy. Interviews with staff confirmed the absence of required equipment, and the facility's policy on oxygen administration was not followed, contributing to the deficiencies observed.
Medication Administration and Narcotic Count Deficiencies
Penalty
Summary
The facility failed to ensure that physician-ordered medications were administered and available for a resident, identified as Resident K, who had significant cognitive impairment and was frequently incontinent of bowel. Despite orders for bisacodyl, docusate sodium, and milk of magnesia to manage constipation, Resident K did not receive these medications as prescribed from August 26, 2024, to August 29, 2024. There was no documentation in the nursing progress notes or the facility's bowel tracking system to indicate that Resident K had regular bowel movements during this period. Additionally, the facility did not maintain accurate narcotic count documentation. An observation of the medication cart revealed that the narcotic logbook lacked 24 signatures, indicating that narcotic counts were not completed every shift as required. An LPN confirmed that the narcotic log sheets should have been signed every shift. The facility's policies on ordering and receiving medications and controlled medication storage were not adhered to, contributing to these deficiencies.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals, as observed during a survey. On the 400 hall medication cart, six loose pills were found in three of the four main drawers. An LPN confirmed that loose pills should not be present in the medication cart. Similarly, on the 100 hall medication cart, a box of expired glucose test strips, three loose pills in two drawers, and an opened container of Miralax without an opened date were found. An RN acknowledged that loose pills should not be in the medication cart and that the laxative should have a date indicating when it was opened. The Director of Nursing provided the facility's policy on medication cart disinfecting, which stated that the medication cart should be maintained in a clean and orderly manner at all times. However, the observations indicated non-compliance with this policy, as evidenced by the presence of loose pills, expired items, and improperly labeled medications.
Infection Control Deficiencies in Wound Care and Catheter Management
Penalty
Summary
The facility failed to implement enhanced barrier precautions during wound care for a resident with multiple diagnoses, including rhabdomyolysis, atrial fibrillation, and a pressure ulcer. Despite a physician's order and a visible instruction sign for enhanced barrier precautions, staff members did not wear gowns or face masks while performing wound care. Interviews with employees confirmed that enhanced barrier precautions required the use of gowns and gloves during such procedures, indicating a lapse in adherence to infection control protocols. Additionally, the facility did not properly store catheter tubing and drainage bags for another resident with a Foley catheter. Observations revealed that the urinary catheter drainage bag was resting on the floor, and the drainage tube was filled with urine, preventing proper drainage. The facility's policy required that catheter tubing and drainage bags be kept off the floor, which was not followed in this instance. An LPN acknowledged that the drainage bag was not standard for the facility and confirmed that the tubing should not be on the floor.
Resident Improperly Restrained with Bed Sheet
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident C, was free from physical restraints, as required by regulations. On the evening of August 13, 2024, Employees 4 and 5 used a bed sheet to secure Resident C to his wheelchair by tying it around the back of the chair. This action was taken while Resident C was being supervised on the West Wing, and it was later discovered by Employee 14 when the resident was returned to his room on the East Wing. Employee 16 reported the incident to the Administrator, but no immediate action was taken against Employees 4 and 5 pending an investigation. Resident C, who has diagnoses including dementia and is severely cognitively impaired, was dependent on a wheelchair and staff assistance for locomotion needs. The resident displayed behaviors such as reaching for things and attempting to stand up from the wheelchair, which led Employees 4 and 5 to use the sheet as a restraint. Despite Employee 4's claim that the sheet was intended to provide dignity and not to restrain movement, the Director of Nursing confirmed that such an intervention was inappropriate and should have been reported. The facility did not conduct a thorough investigation into the incident, as acknowledged by the Administrator.
Failure to Report and Investigate Alleged Abuse Involving Physical Restraint
Penalty
Summary
The facility failed to implement its abuse prevention policy when an allegation of abuse involving the use of a physical restraint on a resident was not reported to the State Agency. The incident involved Resident C, who was secured to his wheelchair with a sheet by two staff members, Employees 4 and 5. Employee 16 reported the incident to the Administrator, but neither Employee 4 nor Employee 5 were suspended pending an investigation, as required by the facility's policy. Interviews revealed that Employee 5, who was supervising Resident C, did not report the incident to the Director of Nursing or the Administrator due to fear of job repercussions. Employee 4 and Employee 5 placed a bed sheet over Resident C's lap and tied it behind the wheelchair, allegedly to prevent the resident from falling or getting up. However, Employee 4 claimed the sheet was intended to provide dignity and not to restrain the resident. The Director of Nursing was unaware of the incident until the survey, although Employee 13 indicated that the Director of Nursing had discussed suspending Employee 4. The Administrator reviewed video footage and did not observe any restraint, but acknowledged that the facility failed to investigate the allegation further. Resident C, who has diagnoses including dementia and is dependent on a wheelchair, was described as severely cognitively impaired and displaying behaviors that disrupted the living environment. The facility's policy mandates immediate suspension of employees involved in abuse allegations and reporting to the Administrator, which was not followed in this case.
Failure to Report Alleged Abuse of Resident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as Resident C, to the State Agency. The incident occurred when two staff members, Employees 4 and 5, secured Resident C to his wheelchair using a bed sheet. Employee 16 reported that on the evening of the incident, Employee 4 tied the sheet around the back of the wheelchair while Resident C was on the West Wing for supervision. This was discovered by Employee 14 when the resident was returned to his room on the East Wing. Although Employee 15 reported the incident to the Administrator, Employees 4 and 5 were not sent home pending an investigation. Employee 5 admitted to participating in the act, stating that Resident C was very active and attempting to stand up from the wheelchair. She and Employee 4 used a bed sheet to secure the resident to prevent him from falling. Employee 5 did not report the incident to the Director of Nursing (DON) or the Administrator due to fear of job repercussions. Employee 4, during a telephone interview, claimed the sheet was used to provide dignity and was not intended as a restraint, although it was tied behind the wheelchair. The Director of Nursing was unaware of the incident until the survey, despite Employee 13 indicating that the DON had discussed suspending Employee 4. The Administrator confirmed the incident was reported to her, but the facility did not conduct a thorough investigation or report the allegation to the State. Resident C's clinical record indicated severe cognitive impairment and dependency on staff for daily activities, highlighting the vulnerability of the resident involved in the incident.
Failure to Investigate Alleged Abuse of Resident
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving Resident C, who was reportedly secured to his wheelchair with a sheet by two staff members, Employees 4 and 5. Employee 16 reported that on the evening of 8/13/24, the resident was tied to his wheelchair with a sheet by these employees. Despite the incident being reported to the Administrator, neither Employee 4 nor Employee 5 were suspended pending an investigation, as per the facility's policy. Interviews with the involved staff revealed discrepancies in their accounts. Employee 5 admitted to assisting Employee 4 in placing a sheet over Resident C's lap and tying it behind the wheelchair to prevent the resident from falling or standing up. However, Employee 4 claimed the sheet was used to provide dignity and was not intended as a restraint. The Director of Nursing was initially unaware of the incident until the survey, although it was later indicated that she had discussed suspending Employee 4. The Administrator reviewed video footage but did not observe the sheet being tied, and acknowledged that the facility did not investigate the allegation further. Resident C's clinical record indicated severe cognitive impairment and dependency on staff for daily activities, including mobility in a wheelchair. The facility's policy on abuse prevention required immediate suspension of employees pending investigation of abuse allegations, which was not followed in this case. The failure to properly investigate and address the incident involving Resident C represents a deficiency in the facility's handling of abuse allegations.
Failure to Monitor Hot Liquid Temperatures Leads to Resident Burns
Penalty
Summary
The facility failed to monitor the temperatures of coffee and hot water before serving them to residents, which led to a resident, identified as Resident B, spilling hot liquid onto her lap and sustaining second-degree burns on her legs. Observations revealed that Resident B had significant burns on both thighs, with blisters and raw tissue. Interviews with staff indicated that the kitchen and dining staff had not been checking the temperatures of hot liquids from the dispensers until after the incident occurred. Resident B, who had a history of dementia, delusional disorder, anxiety, and mild cognitive impairment, was having breakfast in the dining room when she spilled her mug of hot tea. The resident was known to use her personal large mug and required minimal assistance with meals. Staff interviews revealed that Resident B was capable of holding her own cup, but the mug was likely too hot, leading to the spill. The facility had not conducted a hot liquid safety evaluation for Resident B prior to the incident, despite her cognitive impairments and poor decision-making abilities. The Dietary Manager and other staff confirmed that the facility had not been monitoring the temperatures of hot liquids from the dispensers or carafes before the incident. The facility's policy required regular hot liquid safety evaluations and documentation of risk factors for burns, but these measures were not implemented for Resident B until after she sustained burns. The facility also lacked temperature logs for hot liquids prior to the incident, indicating a failure to adhere to their own safety protocols.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 219 citations issued within 25 miles in the last 12 months — including the 1 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Plymouth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Miller's Merry Manor | 1.5 mi | ★★★★★ | 0 | 0 |
| Miller's Merry Manor | 10.6 mi | ★★★★★ | 15 | 0 |
| Signature Healthcare Of Bremen | 11.1 mi | ★★★★★ | 18 | 1 |
| Miller's Merry Manor | 11.9 mi | ★★★★★ | 24 | 0 |
| Brickyard Healthcare - Knox Care Center | 16.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.