Pilgrim Manor
222 Parkview St, Plymouth, IN 46563 · Marshall County · 78 certified beds · avg 65 residents/day · certified since May 22, 1968
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Feb 13, 2026 · F-0691
The facility did not provide proper care for residents with a colostomy, urostomy, or ileostomy — surgical openings in the abdomen that let waste leave the body into a pouch. These require regular, skilled attention to stay clean and healthy.
Why it matters: Poor ostomy care leads to skin breakdown, infection, pain, and embarrassment for the resident.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 19, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 27, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 27, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (33)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 1, 2026 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. · from a complaint |
| Jun 1, 2026 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Apr 16, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Feb 13, 2026 | ▲ G · Actual harm, one-off | The facility did not provide proper care for residents with a colostomy, urostomy, or ileostomy — surgical openings in the abdomen that let waste leave the body into a pouch. These require regular, skilled attention to stay clean and healthy. |
| Feb 13, 2026 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 13, 2026 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 13, 2026 | E · Potential for harm, repeated | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Feb 13, 2026 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Feb 13, 2026 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Feb 13, 2026 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Feb 13, 2026 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. |
| Feb 13, 2026 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Feb 13, 2026 | D · Potential for harm, one-off | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Feb 13, 2026 | D · Potential for harm, one-off | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Nov 27, 2024 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Nov 27, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Nov 27, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Nov 27, 2024 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Nov 27, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Nov 27, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Nov 27, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Nov 27, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Nov 27, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Nov 27, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Nov 27, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 28, 2024 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint |
| Aug 28, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Aug 28, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Aug 28, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Aug 28, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Dec 22, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Dec 22, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Dec 22, 2023 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (11 → 11).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 3 | 0 | F |
| 2024 | 16 | 1 | G ▲ |
| 2026 | 14 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $45,580.
| Date | Type | Amount / length |
|---|---|---|
| Feb 13, 2026 | Fine | $45,580 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Indiana avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.95 | 3.42 | 3.95 | bottom 24% in Indiana; bottom 12% in the U.S. |
| Registered Nurse hours | 0.53 | 0.62 | 0.69 | bottom 45% in Indiana; bottom 43% in the U.S. |
| Weekend total nurse staffing | 2.65 | 3.01 | 3.50 | bottom 30% in Indiana; bottom 14% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.38 | 0.47 | 0.48 | bottom 43% in Indiana; bottom 48% in the U.S. |
| Total nursing staff turnover (%) | 39.1 | 45.9 | 45.8 | top 30% in Indiana; top 34% in the U.S. |
| RN turnover (%) | 42.9 | 40.4 | 42.9 | bottom 47% in Indiana; bottom 49% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.43, RN 0.62, weekend 3.08. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 4/5 · short-stay residents: 5/5
Who owns this facility
Government - County
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| 222 Parkview Propco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
| Adams County Memorial Hospital | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2025 |
| Advanced Care Consultants LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
| Blue Management Services LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
| Borne-Bauman, Candice | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2024 |
| Borne-Bauman, Candice | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Clinical Consulting Services LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
| Combs, James | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/10/2024 |
| Combs, James | Individual | ADP of the SNF | NOT APPLICABLE | 10/10/2024 |
| First Bank of Berne | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
| Flueckiger, Russell | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2024 |
| Flueckiger, Russell | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Greatorex, Tina | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 08/06/2025 |
| Holm, Byron | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Holm, Byron | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
| Lehman, Scott | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2024 |
| Lehman, Scott | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Macklin, Larry | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2024 |
| Macklin, Larry | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| McIntire, David | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Which staff are trained in ostomy care, and how often is that care provided and checked?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How do you explain health changes and treatment options to residents and their families?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Miller's Merry Manor | 1.5 mi | Plymouth, IN | ★★★★☆ | 3/5 | |
| Miller's Merry Manor | 10.6 mi | Culver, IN | ★★★☆☆ | 3/5 | |
| Signature Healthcare of Bremen | 11.1 mi | Bremen, IN | ★☆☆☆☆ | 1/5 | |
| Miller's Merry Manor | 11.9 mi | Walkerton, IN | ★★☆☆☆ | 2/5 | abuse |
| Brickyard Healthcare - Knox Care Center | 16.6 mi | Knox, IN | ★★★★★ | 4/5 | |
| Southfield Village | 18.1 mi | South Bend, IN | ★★★☆☆ | 2/5 | |
| Waters of Wakarusa Skilled Nursing Facility, the | 19.8 mi | Wakarusa, IN | ★☆☆☆☆ | 1/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 155073.