Pilgrim Rehabilitation and Skilled Nursing Center

Pilgrim Rehab

MI Elder Abuse Free Legal ConsultationPilgrim Rehabilitation & Skilled Nursing Center, Fines, Reviews, and Complaints .

Abuse of the elderly is not acceptable and we fight hard in these types of cases. If you suspect a nursing home or caregiver has caused harm to your loved one in someone elses’ care, contact our law firm today for a free legal consultation.

Talking to us does not obligate you to anything, but we may be able to tell you if you have a claim and the value of your case. If we accept your case, you pay no fee unless we recover for you.

About Pilgrim Rehabilitation & Skilled Nursing Center

Pilgrim Rehabilitation & Skilled Nursing Center is a for profit, 152-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Salem, Beverly, Danvers, Swampscott, Marblehead, Lynn, Saugus, Lynnfield, Middleton, Wakefield, MA North Reading, Melrose, Reading, Revere, Stoneham, and the other towns in and surrounding Essex County, Massachusetts.

Pilgrim Rehabilitation & Skilled Nursing Center
96 Forest St
Peabody MA 01960

Phone: (978) 532-0303
Website: https://pilgrimrehab.org/

CMS Star Quality Rating

Pilgrim RehabThe Centers for Medicare and Medicaid (CMS) rates all nursing homes that accept medicare or medicaid benefits. CMS created a 5 Star Quality Rating System—1 star is the lowest rating and 5 stars is the highest—that look at three areas.

As of 2018, Pilgrim Rehabilitation & Skilled Nursing Center in Peabody, Massachusetts received a rating of 5 out of 5 stars.

Performance Area Rating
Overall Rating 5 out of 5 (Much Above Average)
State Health Inspections 5 out of 5 (Much Above Average)
Staffing 4 out of 5 (Above Average)
Quality Measures 4 out of 5 (Above Average)

Fines Against Pilgrim Rehabilitation & Skilled Nursing Center

The Federal Government has not fined Pilgrim Rehabilitation & Skilled Nursing Center in the last 3 years.

Fines and Penalties

Our Nursing Home Accident Lawyers inspected government records and discovered Pilgrim Rehabilitation & Skilled Nursing Center committed the following offenses:

Allow residents to self-administer drugs if determined clinically appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to complete interdisciplinary assessments for self-administration of medications, report the findings of the assessment to self-administer medications and have an interdisciplinary team evaluation for the ability to self administer medications for 1 Resident (#184) in a total sample of 32 residents.

Findings include:

Resident #184 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident was cognitively intact and interviewable. The Resident was greeted during the initial tour of the Facility on 3/15/18 at 12:02 P.M. The Resident was observed to have a Proair inhaler (a medicine to treat shortness of breath or wheezing) on his/her bedside table in plain view. The Resident said it is always with him/her – I have [MEDICAL CONDITION]. They know I have it. They have one too. On 3/16/18 at 2:39 P.M., the Resident was observed to still have the Proair inhaler on his/her overbed table.

The Resident’s medical record was reviewed on 3/15/18 at 2:07 P.M. There was no evidence to indicate an assessment by the interdisciplinary team for self-administration of medications was completed for the Proair inhaler medication.

Review of the Physician’s order sheet dated 3/11/18 indicated the Resident was ordered to receive Proair ([MEDICATION NAME]) HPA 90 MCG. inhalation four times a day. Inhale 2 puffs. The physician’s order sheet did not contain an order for [REDACTED]. On 3/20/18 at 4:04 P.M., The Resident said the staff took his/her Proair inhaler and they are now administering it. He/She is no longer administering it. However, the Surveyor now observed a bottle of [MEDICATION NAME] (a medicine to treat chest pain) 0.4 mg at his/her bedside in the plastic wash basin and [MEDICATION NAME] cream (an antifungal medicine) on the bedside table.

The Resident said he/she had not told the staff about the [MEDICATION NAME] and he/she does not think he/she has taken it in about 3 months. The Resident said he/she had a [MEDICAL CONDITION] a while ago and he/she needs it in case of an emergency. The Resident said he/she puts the [MEDICATION NAME] cream on his/her genital area after he/she washes up and when it is itchy. The Resident’s medical record was reviewed on 3/20/18 at 4:22 P.M. There was no evidence in the medical record to indicate that an assessment for self-administration of medication for the [MEDICATION NAME] or the [MEDICATION NAME] cream had been completed. Review of the current physician’s orders included an order for [REDACTED]. There was no physician’s order for [MEDICATION NAME] cream.

The Assistant Director or Nursing (ADON)/Unit Manager was interviewed on 3/20/18 at 4:30 P.M. The ADON accompanied the Surveyor to the Resident’s bedside and was shown the [MEDICATION NAME] medication and the [MEDICATION NAME] cream. The ADON said she was not aware that the Resident had the medications at the bedside, nor was the nurse assigned to the Resident that day aware of them. The ADON reviewed the medical record and acknowledged there was no self administration assessment form for the the [MEDICATION NAME] or the [MEDICATION NAME] cream and no physician’s order for self-administration of either medication. There was no care plan for self-administration of these medications. Review of the Facility policy titled Self Administration of Medications dated 8/2/2013, indicated that The resident will be assessed for cognitive, physical and visual ability to self administer medications upon admission, quarterly, and as needed with significant change in status. The procedure indicated that, point 2, Upon admission, the Self Administration of Medications Informed Consent and Assessment Tool will be completed. Point 4. Ensure MD orders are in place. Point 5. Provide safe, locked storage if keeping medications at the bedside. Point 6. Medication Nurse will monitor resident’s compliance and record on the MAR.

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to ensure a baseline plan of care was developed for 1 Resident (#126) out of total of 3 closed records reviewed.

Findings include:

For Resident #126 the Facility failed to ensure a baseline plan of care was developed within 48 hours of a resident’s admission to include the minimum healthcare information necessary to provide effective and person-centered care for a resident that meets professional standards of quality.

Resident #126 admitted to the Facility 12/13/17 with a [DIAGNOSES REDACTED].#126 required a Peripherally Inserted Central Catheter (PICC line) for the administration of an antibiotic.

Review of the clinical record on 3/20/18 indicated there was no evidence of nursing assessments or a care plans related to the care of the PICC line.

During an interview with the Director of Nurses on 3/23/18 at 1:00 P.M., she said she was not able to find any further information. She said it may have been missed because Resident #126 admitted on the 12/13, went to the hospital on the 12/16.

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a plan of care for the monitoring of a cardiac pacemaker for 1 Resident (#181) out of a total sample of 32.

Findings include:

1. For Resident #181, the Facility failed to develop and implement a plan of care for the monitoring of a cardiac pacemaker.

Resident #181 was readmitted to the Facility in 3/2018 after having surgery on the right femoral artery for severe [MEDICAL CONDITION]. The Resident was receiving intravenous antibiotics through a peripherally inserted midline catheter placed on 3/14/18 because the surgical site had become infected and dehisced (the wound opened). The Resident also had a [MEDICAL CONDITION], gastric tube through which feedings infused during the night shift for the provision of additional calories to promote multiple wound healing. The Resident had an unstageable pressure ulcer on the left heel and right toe, an area of [MEDICAL CONDITION] on the top of the right ankle and an open, partially healed surgical area on the mid-abdominal area. Other [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] indicated the Resident required the extensive assist of 2 staff for transfer and activities of daily living.

On 3/22/18 at 10:00 A.M. during a review of the medical record, the ADL Rehabilitation Potential care plan had a handwritten notation in the corner of the sheet indicating the resident had a pacemaker. Further review of the medical record indicated there was no evidence the facility had obtained information regarding the specifics of the pacemaker or follow up required, such as: type of pacemaker, serial number, contact information for the cardiology service, or a physician’s orders [REDACTED].

The Assistant Director of Nursing/Unit Manager (ADON) was asked to review the chart for further information on the type and make of the Resident’s pacemaker. The ADON was able to locate some information in the discharge summary from the Rehabilitation Hospital where the Resident had been cared for after surgery. The ADON then called the Cardiology service to determine when Resident #181’s last pacemaker check was done and obtained a physician’s orders [REDACTED].M. for pacer check – every two months. The clinic name and contact number were also documented and that the Med. Alert System was at the bedside.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the Facility failed to ensure that the plan of care was revised and implemented to include the use of straws with all drinks for 1 Resident (#274) out of a total sample of 32 Residents.

Findings include:

Resident #274 admitted to the facility to the Facility 10/2017 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #274 requires extensive assistance with activities of daily living, including bathing, dressing, grooming and eating, and scored a 1/15 on the brief interview of mental status indicating severe cognitive impairment. Review of the clinical record indicated that there was a physician order, dated 3/22/18, to provide straws with all drinks.

On 3/22/18, Surveyor observed Resident #274 at breakfast with two drinks. 1 had a straw and 1 did not. There was some liquid and food debris on the left side of the Resident’s face just below the lip. On 3/22/18, Surveyor observed Resident #274 at lunch with two drinks. Neither drink had a straw.

During an interview with the Speech Therapist on 3/22/18 at 1:30 P.M., she said that Resident #1 needs to use straws to help control spillage out of the left side of the mouth and to help with controlling swallowing. She provided a nursing education/carryover sheet that had begun 3/16/18 indicating that nursing please provide Resident #274 with a straw with all drinks, this helps to hold the liquids in the mouth and to swallow the liquids without coughing. 4 staff members had signed the education sheet. During an interview with Nurse #2, on 3/22/18 she said that Resident #274 should have a straw with all drinks. During an interview with Certified Nursing Assistant (CNA) #3, on 3/23/18 at 12:15 P.M., she said that she was caring for Resident #274 that day and was not aware that straws were needed with all drinks.

Review of the Resident Profile (a document on the computer that CNA’s use to know a resident’s plan of care) failed to include the use of straws for all drinks. Review of Resident #274’s Interdisciplinary Care Plan failed to indicate the use of straws for all drinks.

Ensure services provided by the nursing facility meet professional standards of quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the Facility staff failed to follow Professional Standards of Practice during medication pass and when administering medications for 1 Resident (#104) in a total sample of 32 residents.

Findings include:

1. Resident #104 was admitted with [DIAGNOSES REDACTED]. The Resident was interviewed on 3/21/18 at 1:38 P.M. The Resident told the Surveyor that he/she received pills on the evening shift on 3/16/18 at approximately 5:00 P.M. and did not know what all the medications were. The Resident said that the nurse who administered the medication was not his/her assigned nurse. The Resident said that he/she observed that the nurse looked at the name on the door after administering the medications. Resident #104 said that his/her assigned nurse entered the room at approximately 5:30 P.M. to administer medications. The Resident said that he/she told his/her assigned nurse that his/her medications, including [MEDICATION NAME], had already been given by the other nurse. The assigned nurse left the room and returned with the other nurse. At that time, both nurses explained to the Resident that he/she had received Tylenol in error, but had not received the [MEDICATION NAME].

Review of the medication variance report indicated that the nurse gave Resident #104 Tylenol 650 mg at 5:00 P.M. The report indicated that the nurse mistakenly identified Resident #104 as another resident (who resided in the next room) who had asked for Tylenol. The nurse wrote that she was new to the floor and needs to check the bracelets until I become more acclimated to the residents. The variance report indicated that Resident #104 had a physician order [REDACTED]., 2:00 P.M. and 10:00 P.M. After discovery of the medication variance, the nurse notified the Nurse Practitioner and received a telephone order to hold the 10:00 P.M. Tylenol dose. 2. The Facility failed to ensure that Professional Standards of Practice were followed during medication administration.

The Surveyor observed Nurse #1 administer medications to Resident #36 on 3/21/18 at 9:32 A.M. While reconciling the observations for accuracy, Nurse #1 approached the Surveyor and stated that she was administering an additional medication to Resident #36, [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION]) 5 milligrams (mg). Nurse #1 had a small green colored pill in a cup. Nurse #1 said that she had obtained the medication from the emergency medication supply. When the Surveyor asked where the emergency medication supply was located, Nurse #1 said she had not obtained the mediation the from the emergency medication supply, but instead had borrowed the medication from another resident’s medication supply. Nurse #1 said the Facility policy is to only use the emergency supply and medications should not be borrowed from another resident’s medication supply.

During an interview with Unit Manager #2 on 3/21/18 at 10:16 A.M., she said that if a medication is not available, it should be only obtained from the emergency supply. Unit Manager #2 said that medications should not be borrowed from other residents. Review of an undated document titled Medication Administration Practice Standards, indicated that if medications are not available: 1st – Do Not Borrow from other Residents, 2nd – Use emergency supply.

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of documentation and interviews, the Facility failed to ensure that a residents were assessed for the continued medical necessity of a Foley catheter, received appropriate care and treatment to prevent infection and provide restorative care to regain bladder function as soon as possible for 1 Resident (#181) out of a total sample of 32 residents.

Findings include:

Resident #181 was re-admitted to the facility on [DATE] after having surgery on the right femoral artery for severe [MEDICAL CONDITION]. The right groin area had become infected and the stitches were open, leaving a wound which required packing and daily dressings. The Resident was initially receiving an intravenous antibiotic through a peripheral intravenous catheter and then through a peripherally inserted midline catheter placed on 3/14/18. The Resident also had a [MEDICAL CONDITION], a gastric tube through which feedings infused during the night shift for the provision of additional calories to promote multiple wound healing, unstageable pressure ulcer on the left heel and right toe, an area of [MEDICAL CONDITION] on the top of the right ankle and an open, partially healed surgical area on the mid-abdominal area. Other [DIAGNOSES REDACTED].

Review of the Quarterly Minimum (MDS) data set [DATE] indicated the Resident required extensive assist of 2 staff for transfer and activities of daily living. The section titled bowel and bladder function indicated the Resident had a foley catheter. Review of the physician’s orders and the care plans indicated no evidence of physician orders or care plan for the Foley catheter. Review of the Resident’s Urinary Incontinence Questionnaire/Assessment form, undated, indicated the Resident had functional incontinence based on physical limitations to physically removing clothes and walking to the bathroom. The form was incomplete and did not include any quarterly reviews.

Review of the Resident’s first admission nursing assessment dated [DATE], section on Bowel and Bladder Elimination Assessment indicated the Resident was occasionally incontinent of bladder and uses the toilet, urinal and briefs.

Review of the re-admission nursing assessment dated [DATE] indicated the Resident had a Foley catheter. Review of the Rehabilitation Hospital discharge summary indicated the Resident had previously had a Foley catheter inserted, but it was removed on 12/14/17 and the Resident was voiding on his own with no difficulty. The hospital discharge summary indicated that a Foley catheter was reinserted on 3/7/18.

The Assistant Director of Nursing/Unit Manager (ADON) was interviewed on 3/22/18 at 8:00 A.M. The Surveyor asked the ADON where information on the Foley catheter could be located in the medical record or electronic medical record. The ADON was not aware the Resident had a Foley catheter and obtained a physician order on 3/22/18 at 11:00 A.M. as follows: Indwelling Foley catheter 16 french- 10 mm to CDB- check shiftly. Foley cath. care every shift. Foley catheter leg strap on – change weekly and PRN.

Review of the Facility Policy titled Indwelling Urinary Catheter Removal dated 8/12/2009 indicated that It is the policy of this facility to provide appropriate assessment and intervention regarding the removal of indwelling catheters for all resident evidenced by completing of the Indwelling Urinary Catheter Assessment, the catheter removal process, if indicated and development of an individualized plan of care to ensure optimal function. The section titled Purpose indicated that To define mechanisms and procedures to provide an environment and a plan for removal of indwelling urinary catheters to create optimal well being and assist residents to their highest level of functioning. The section titled Procedure indicated the resident will be assessed for exclusions or medical justification which would prohibit removal of the indwelling urinary catheter. The Resident did not have a medical [DIAGNOSES REDACTED].

The Assistant Director of Nursing/Unit Manger (ADON) was interviewed on 3/23/18 at 8:21 A.M. There was no evidence of any information in the Certified Nurse Aides (CNA’s) documentation regarding daily shift foley care. The ADON said that because she just wrote the order yesterday, it would not be recorded in the treatment plan records for documentation of the foley care. The Resident returned from the Hospital with a foley catheter on 3/8/18 and it remained in place through 3/23/18, a total of 16 days, with evidence in the medical record to indicate that foley care was provided.

CNA #1 was interviewed on 3/23/18 at 8:35 A.M. Review of the week’s assignment sheet indicated that CNA #1 had cared for the resident since returning from the hospital. CNA #1 said that he would empty the bag and clean the area, however, there was no evidence of any CNA documentation to indicate that Foley care was provided. CNA #2, who also provided care to the Resident, was interviewed on 03/23/18 at 9:04 A.M. CNA #2 said that he cared for the Resident on the evening shift. CNA #2 said that he empties the catheter bag and records the amount, but he did not clean the area. Because the Facility did not obtain an order for [REDACTED]. A final review of the medical record and physician’s order sheet on 3/23/18 at 12:30 P.M., after the Nurse Practitioner had made rounds, indicated there was no order to remove the Resident’s foley catheter.

Ensure medication error rates are not 5 percent or greater.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the Facility staff failed to ensure that its medication error rate was less than 5%. 1 of 3 Nurses made errors during 2 of 27 opportunities. The medication error rate was 7.41%

Findings include:

1. For Resident #36, the Facility staff failed to ensure that Calcium Acetate (used to prevent high blood [MEDICATION NAME] levels in the blood of patients who are on [MEDICAL TREATMENT] due to severe kidney disease) was administered with meals as per the physician order. Review of the Medication Administration Record [REDACTED].M., 12:00 P.M., and 5:00 P.M., with food.

During medication administration on 3/21/18 at 9:32 A.M., the Surveyor observed Nurse #1 administer Calcium Acetate. The medication was administered 1 hour and 32 minutes later than ordered and without food as ordered. During an interview on 3/21/18 at 9:51 A.M., Nurse #1 said she was not aware that Calcium Acetate needed to be administered with food. She said that breakfast was at 8:00 A.M. and she did not administer the medication with food as ordered. 2. For Resident #36, the Facility staff failed to ensure that a Salon Pas patch (a patch that is placed on the skin and is used for pain relief) was removed as ordered. Review of the Medication Administration Record [REDACTED]. To be applied at 9:00 A.M. and removed at 9:00 P.M.

During medication administration on 3/21/18 at 9:32 A.M., the Surveyor observed Nurse #1 attempt to apply a Salon Pas patch to the cervical spine area of Resident #36. There was already a patch in place. Nurse #1 removed the old patch and applied the new one. During an interview on 3/21/18 at 9:51 A.M., Nurse #1 said that the old patch should not have been there, it should have been removed the night before at 9:00 P.M. as ordered.

Pilgrim Rehabilitation & Skilled Nursing Center, Nursing Home Neglect and Elder Abuse Lawyers

If someone you love has suffered neglect or elder abuse by a senior caregiver, nursing home, or other care facility, our lawyers may be able to help. Regardless of whether or not criminal charges are filed against an alleged abuser, you may still be able to pursue compensation in a civil claim. Compensation in elder abuse cases may be awarded if someone in the care of another suffers harm due to intentional or negligent actions (including failure to take action).

Abuse of the elderly is not acceptable and we fight hard in these types of cases. If you suspect a nursing home or caregiver has caused harm to your loved one in someone elses’ care, contact our law firm today for a free legal consultation. Talking to us does not obligate you to anything, but we may be able to tell you if you have a claim and the value of your case. If we accept your case, you pay no fee unless we recover for you.

Oftentimes, victims of abuse either cannot or will not speak up for themselves out of fear. If you notice any warning signs or symptoms of neglect of abuse an an elderly person, it is important you contact an elder abuse lawyer immediately. Not only are there statute of limitations on filing a claim, but the sooner we start helping you, the easier it will be to collect evidence and talk to any witnesses before important details are lost, hidden, or forgotten.

Boston Personal Injury Lawyers for Elder Abuse Cases

We offer a free, no-obligation legal consultation to help you understand your rights and the value of your case. Our personal injury law firm takes cases involving elder abuse and neglect. We offer legal service to clients in Massachusetts, Rhode Island and New Hampshire.


Sources:

Medicare Nursing Home Profiles and Reports – Pilgrim Rehabilitation & Skilled Nursing Center

Inspection Report for Pilgrim Rehabilitation & Skilled Nursing Center – 03/23/2018

Page Last Updated: October 3rd, 2018