Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Rehabilitation & Skilled Nursing Center during CMS and state inspections, most recent first.
The facility failed to inspect and document all seven zones of bed entrapment, leading to potential safety hazards for two residents. Improper fitting of bolsters created significant gaps, risking entrapment. Maintenance records showed incomplete checks, and the Maintenance Director admitted to not measuring certain zones, contrary to the Administrator's expectations.
The facility failed to maintain resident dignity during meal assistance. A CNA was observed standing over a resident while feeding them in bed, contrary to the facility's policy on Residents' Rights, which emphasizes respect and dignity. Interviews with nursing staff confirmed the expectation for staff to be seated while assisting residents with meals.
The facility failed to implement care plans for three residents, leading to deficiencies in care. A resident at risk for pressure ulcers did not receive ordered booties, another with a DNR order lacked a required bracelet, and a third with cognitive impairments was not provided a low bed as per their fall prevention plan. Staff were unaware or did not adhere to these care plans, resulting in unmet resident needs.
The facility failed to provide appropriate respiratory care for two residents. One resident used a CPAP machine without a physician's order, contrary to facility policy. Another resident received oxygen at an incorrect flow rate, not following the physician's order of 4 liters. Staff did not ensure the resident consistently wore the nasal cannula, as required. These actions indicate a lapse in adherence to respiratory care policies.
A facility failed to administer phosphate binders at the correct time for a resident with chronic kidney disease and dialysis dependence. The resident was prescribed Renvela to be taken with meals, but observations showed the medication was given significantly after meal times. Staff interviews revealed a lack of awareness about the timing requirement, and management acknowledged the need to update the administration schedule to ensure compliance with the physician's order.
The facility failed to maintain accurate medical records for two residents. One resident's MAR inaccurately indicated the use of lower extremity booties, while another resident's MAR incorrectly documented the presence of a DNR bracelet. Observations and interviews revealed discrepancies between the documented care and the actual care provided, highlighting a failure in the facility's documentation practices.
Failure to Inspect Bed Entrapment Zones
Penalty
Summary
The facility failed to regularly inspect and document findings regarding the seven zones of bed entrapment for residents' beds, leading to potential safety hazards. Specifically, the facility did not properly assess and document the spacing between bed frames, mattresses, and bolsters, which could result in entrapment. The FDA guidelines and the facility's own policy require regular inspections to ensure no gaps are wide enough to entrap a resident's head or body, but these were not fully adhered to. Resident #226, admitted with conditions including acute on chronic diastolic heart failure and chronic kidney disease, was observed with a bolster at the foot of the bed that did not fit properly, leaving a gap of about six and a half inches. The facility's maintenance records showed that only some zones of entrapment were checked, leaving others unassessed. This oversight was confirmed during an interview with the Administrator and Maintenance Director, who acknowledged the risk posed by the gaps. Similarly, Resident #228, with diagnoses including epilepsy and anemia, was found with a similar issue of improper bolster fitting, creating a six-inch gap. The Maintenance Director admitted to not measuring certain zones, believing it unnecessary, and used a small ruler for checks. The Administrator expected all zones to be assessed, but this was not done, leading to the deficiency in bed safety inspections.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that staff treated residents in a dignified manner during meal assistance. Specifically, a resident who was dependent on staff for assistance with meals was observed being fed by a Certified Nurses Aide (CNA) who was standing over the resident while they were in bed. This occurred on two separate occasions, as observed by the surveyor. The facility's policy on Residents' Rights, dated 10/4/23, emphasizes the right of residents to be treated with respect and dignity. Interviews with Nurse #3 and the Assistant Director of Nurses (ADON) confirmed that staff are expected to be seated while assisting residents with eating to maintain dignity.
Failure to Implement Resident-Centered Care Plans
Penalty
Summary
The facility failed to implement resident-centered care plans for three residents, leading to deficiencies in care. For Resident #28, who was at risk for pressure ulcers, the facility did not implement the use of bilateral lower extremity booties as ordered by the physician. Despite the resident's intact cognition and the presence of a physician's order, the booties were not observed on the resident during multiple surveyor visits, and there was no documentation of refusal by the resident. Interviews with staff revealed a lack of awareness and adherence to the physician's order. Resident #96, who had a DNR order, was not provided with a DNR bracelet as required by the facility's policy. The resident, who had intact cognition, reported the absence of the bracelet for approximately six weeks and had repeatedly requested a replacement. Despite the presence of DNR bracelets at the nursing station, staff failed to provide one, and the resident's assigned nurse was aware of the missing bracelet but did not take action to replace it. For Resident #92, who had severe cognitive impairments and a history of falls, the facility did not implement the care plan intervention of using a low bed. Observations by the surveyor showed the bed was consistently in a high position, contrary to the care plan's directive. Interviews with nursing staff confirmed the expectation to follow the care plan, yet the intervention was not implemented, indicating a failure to adhere to the resident's fall prevention plan.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in their treatment. For one resident, the facility did not have a physician's order for the use of a CPAP machine, which the resident had been using regularly. Despite the resident's consistent use of the CPAP, as noted in nursing progress notes, and confirmation from both a nurse and a respiratory therapist, there was no documented physician's order for its use. This oversight indicates a failure to adhere to the facility's policy requiring verification of a physician's order for non-invasive positive pressure ventilation. Another resident was not receiving oxygen therapy as per the physician's orders. The resident was observed receiving oxygen at a flow rate of 1.5 liters, contrary to the physician's order of 4 liters to maintain adequate oxygen saturation. Additionally, the resident was found without the nasal cannula on one occasion, and the staff did not ensure the resident was wearing it consistently. The unit manager and the DON acknowledged that the physician's orders were not followed, highlighting a lapse in the facility's adherence to its policy on oxygen administration.
Failure to Administer Phosphate Binders with Meals for Dialysis Resident
Penalty
Summary
The facility failed to administer phosphate binders at the appropriate time for a resident requiring dialysis care, as per the physician's order. The resident, who has stage 4 chronic kidney disease and is dependent on renal dialysis, was prescribed Renvela, a phosphate binder, to be taken with meals. However, observations revealed that the medication was not administered in accordance with the prescribed schedule. On two separate occasions, the resident was observed eating breakfast, but the medication was administered significantly later than the meal times, contrary to the physician's order that specified the medication should be given with meals. Interviews with the nursing staff and management revealed a lack of awareness and adherence to the timing of the medication administration. Nurse #4 admitted to not being aware that the medication needed to be taken with meals and acknowledged that the scheduled administration time was inappropriate. The Unit Manager and the Director of Nursing also confirmed that the medication should be administered with meals and recognized the need to update the administration schedule to align with meal delivery times. This oversight in medication administration timing led to a failure in providing appropriate dialysis care for the resident.
Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to discrepancies in the documentation of their care. For one resident, the Medication Administration Record (MAR) inaccurately indicated that the resident was wearing bilateral lower extremity booties, despite multiple observations by the surveyor that the resident was not wearing them. The resident had a physician's order for the booties due to a risk of pressure ulcers, but there was no documentation of refusal or any indication that the resident was not wearing them as ordered. Interviews with the resident and staff revealed a lack of awareness and communication regarding the resident's use of the booties. Another resident's MAR inaccurately documented that the resident was wearing a Do Not Resuscitate (DNR) bracelet, which was not the case. The resident, who had a DNR code status, reported that the bracelet had been missing for approximately six weeks and had requested a replacement multiple times. Despite this, the MAR continued to reflect that the bracelet was in place. Interviews with the unit manager and the resident's assigned nurse revealed a lack of awareness and communication about the missing bracelet, and the unit manager acknowledged that the documentation was inaccurate. These inaccuracies in the medical records highlight a failure in the facility's documentation practices, as outlined in their policy. The policy requires accurate documentation of medication and treatment administration, as well as acknowledgment of physician orders. The discrepancies observed in the MARs for both residents indicate a failure to adhere to these guidelines, resulting in inaccurate medical records.
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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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Nursing homes near Peabody
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jeffrey & Susan Brudnick Center For Living | 1.2 mi | ★★★★★ | 1 | 0 |
| Care One At Peabody | 1.3 mi | ★★★★★ | 10 | 0 |
| Continuing Care At Brooksby Village | 1.8 mi | ★★★★★ | 12 | 0 |
| New England Homes For The Deaf, Inc | 2.1 mi | ★★★★★ | 0 | 0 |
| Alliance Health At Rosewood | 2.3 mi | ★★★★★ | 8 | 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.