PILGRIM MANOR
Open-data reference.
PILGRIM MANOR is a government - county facility in PLYMOUTH, IN with 78 certified beds and a 2-star overall CMS rating. The facility has 26 deficiency records on file.
222 PARKVIEW ST, PLYMOUTH, IN 46563
Phone: 5749369943
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 155073
- Ownership
- Government - County
- Provider Type
- Medicare and Medicaid
- Beds
- 78
- Residents
- 65
- In Hospital
- No
- County
- Marshall
- Last Inspection
- Nov 27, 2024
Staffing Data
- RN Hours
- 0.65 (nat'l avg: 0.68)
- LPN Hours
- 0.48
- CNA Hours
- 2.13
- Total Nursing Hours
- 3.25 (nat'l avg: 3.89)
- PT Hours
- 0.06
- Nursing Turnover
- 48.7%
- RN Turnover
- 50.0%
What the CMS Record Reveals About PILGRIM MANOR
PILGRIM MANOR operates 78 certified beds in PLYMOUTH, IN with approximately 65 residents currently in care, and carries a CMS overall rating of 2 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (2★), and quality measures (5★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 26 deficiency records from recent surveys, of which 1 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 3.25 total nursing hours per resident day (national average 3.89), with RN coverage at 0.65 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "Government - County" ownership and operating as a "Medicare and Medicaid" provider, PILGRIM MANOR falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 48.7%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (26 most recent)
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.
Category: Pharmacy Service Deficiencies
Corrected: Jan 4, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 27, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Dec 27, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Dec 27, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Jan 4, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 27, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 27, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Dec 27, 2024
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Dec 27, 2024
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Dec 27, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Dec 27, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 21, 2024
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Sep 21, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Sep 21, 2024
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Sep 21, 2024
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Sep 21, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Jan 15, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 15, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jan 15, 2024
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.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 27, 2023
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 27, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 27, 2023
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.
Category: Pharmacy Service Deficiencies
Corrected: Mar 27, 2023
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.
Category: Pharmacy Service Deficiencies
Corrected: Mar 27, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 27, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 27, 2023
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 22.3% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 8.5% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.5% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 5.6% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 8.0% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 3.6% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 93.5% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 81.2% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.8% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 20.2% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 15.2% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 97.1% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 79.2% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 3.6% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 27.1% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 8.1% | Yes |
Penalty History
No penalties on record.
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Understanding Nursing Home Data
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Doctors Nearby
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Hospital quality ratings and safety data for PLYMOUTH, IN on PlainHospital
Medicare Plans
Compare Medicare plans and coverage options near PLYMOUTH, IN on PlainMedicare
County Health Data
Health outcomes, access, and quality metrics for Marshall on PlainHealth
Frequently Asked Questions
What is the overall CMS rating for PILGRIM MANOR?
What are the staffing levels at PILGRIM MANOR?
How many beds does PILGRIM MANOR have?
Does PILGRIM MANOR have any deficiencies on record?
Has PILGRIM MANOR received any fines or penalties?
Who owns PILGRIM MANOR?
When was PILGRIM MANOR last inspected?
What quality measures are tracked for PILGRIM MANOR?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.