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Deficiency Records for Pilgrim Place Health Services Center
A list of the most recent deficiencies for Pilgrim Place Health Services Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Pilgrim Place Health Services Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-08-02 | 2024-09-09 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-07-03 | 2024-07-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-06 | 2023-11-13 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-10-06 | 2023-11-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-06 | 2023-11-13 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-10-06 | 2023-11-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-06 | 2023-11-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-06 | 2023-11-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-06 | 2023-11-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-06 | 2023-11-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-06 | 2023-11-13 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-10-06 | 2023-11-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-06 | 2023-11-13 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-10-06 | 2023-11-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-06 | 2023-11-13 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-06 | 2023-11-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-06 | 2023-11-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-06 | 2023-11-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-29 | 2023-09-22 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-10-26 | 2022-11-26 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-10-26 | 2022-11-26 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-10-26 | 2022-11-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-26 | 2022-11-26 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-10-21 | 2022-11-18 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-10-21 | 2022-11-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-21 | 2022-11-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-21 | 2022-11-18 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-10-21 | 2022-11-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-21 | 2022-11-18 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-10-21 | 2022-11-18 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-10-21 | 2022-11-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-21 | 2022-11-18 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-10-21 | 2022-11-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-21 | 2022-11-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-18 | 2022-01-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-19 | 2021-12-30 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-09-22 | 2019-10-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-22 | 2019-10-18 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-09-16 | 2019-10-11 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-09-16 | 2019-10-11 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-09-16 | 2019-10-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-16 | 2019-10-11 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-09-16 | 2019-10-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-16 | 2019-10-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-16 | 2019-10-11 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-09-16 | 2019-10-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-09-16 | 2019-10-11 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-09-16 | 2019-10-11 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-09-16 | 2019-10-11 | N |
| Post nurse staffing information every day. | Health | 2019-09-16 | 2019-10-11 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-09-16 | 2019-10-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-16 | 2019-10-11 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-09-16 | 2019-10-11 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-09-16 | 2019-10-11 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-09-16 | 2019-10-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-16 | 2019-10-11 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-09-16 | 2019-10-11 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-09-16 | 2019-10-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-16 | 2019-10-11 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-09-16 | 2019-10-11 | N |
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