Cycle 1
Health 2024-11-27 · Fire 2024-11-27
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Plymouth, IN
Pilgrim Manor
2-star overall rating with 1-star inspections with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
222 Parkview St, Plymouth, IN
(574) 936-9943
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
78
Certified beds
Average residents
65
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1968-05-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.65
Registered nurse staffing
LPN hours / resident day
0.48
Licensed practical nurse staffing
Aide hours / resident day
2.13
Nurse aide staffing
Weekend hours
2.89
Weekend nurse staffing
RN turnover
50%
Annual RN turnover
Total nurse turnover
49%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.6
0.2 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.5% |
93.6%
0.1 pts worse
|
93.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.1% |
95.4%
1.7 pts better
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
3.8%
0.2 pts better
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 8.0% |
24.6%
16.6 pts better
|
11.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 8.5% |
5.6%
2.9 pts worse
|
5.4%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.2% |
23.5%
8.3 pts better
|
19.6%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 8.1% |
14.8%
6.7 pts better
|
16.7%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.2% |
13.3%
6.9 pts worse
|
16.3%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.3% |
11.7%
10.6 pts worse
|
14.9%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.4%
0.1 pts worse
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 5.6% |
1.2%
4.4 pts worse
|
1.7%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.1% |
24.2%
2.9 pts worse
|
19.8%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
4.1%
0.5 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.2% |
81.6%
0.4 pts worse
|
81.7%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.7% |
10.5%
7.8 pts better
|
12.0%
9.3 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.3%
0.5 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.2% |
79.0%
0.2 pts better
|
79.7%
0.5 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.4% |
22.4%
1 pts worse
|
23.9%
0.5 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-22 · Fire 2023-12-22
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2023-02-15 · Fire 2023-02-15
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-09
F · Potential for more than minimal harm
2024-11-27
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-01-09
E · Potential for more than minimal harm
2024-11-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-09
F · Potential for more than minimal harm
2024-01-22
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-02-12
F · Potential for more than minimal harm
2024-01-22
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-02-12
F · Potential for more than minimal harm
2023-12-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-25
E · Potential for more than minimal harm
2023-12-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-01-30
F · Potential for more than minimal harm
2023-02-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-23
E · Potential for more than minimal harm
2023-02-15
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-03-23
E · Potential for more than minimal harm
2023-02-15
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2023-03-23
Inspection history
Recent health citations
G · Actual harm
2024-11-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-27
E · Potential for more than minimal harm
2024-11-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-11-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-11-27
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-11-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-11-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-11-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-11-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-11-27
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-01-04
D · Potential for more than minimal harm
2024-11-27
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-01-04
D · Potential for more than minimal harm
2024-11-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-08-28
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-09-21
D · Potential for more than minimal harm
2024-08-28
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-09-21
D · Potential for more than minimal harm
2024-08-28
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-09-21
D · Potential for more than minimal harm
2024-08-28
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-09-21
D · Potential for more than minimal harm
2024-08-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-21
F · Potential for more than minimal harm
2023-12-22
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-22
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-02-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-15
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-15
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-15
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-15
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-03-27
Penalties and ownership
What sits behind the stars
Ownership
Adams County Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Adams County Memorial Hospital
Operational/Managerial Control · Organization
Borne-Bauman, Candice
Operational/Managerial Control · Individual
Combs, James
Operational/Managerial Control · Individual
Flueckiger, Russell
Operational/Managerial Control · Individual
Holm, Byron
Operational/Managerial Control · Individual
Lehman, Scott
Operational/Managerial Control · Individual
Macklin, Larry
Operational/Managerial Control · Individual
Mcintire, David
Operational/Managerial Control · Individual
Nbh Bank
5% Or Greater Mortgage Interest · Organization
Pilgrim Manor Operations
Operational/Managerial Control · Organization
Smith, Scott
Operational/Managerial Control · Individual
Sprunger, Kyle
Operational/Managerial Control · Individual
Wheeler, Dane
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Miller's Merry Manor
Plymouth, IN
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Miller's Merry Manor
Culver, IN
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Signature Healthcare Of Bremen
Bremen, IN
2-star overall rating with 2-star inspections with 11 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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