Pilgrim Manor
Plymouth, Marshall County, Indiana · CCN 155073 · Government (County) · not part of a chain
CMS rates Pilgrim Manor 2 of 5 overall as of August 2026. 78 certified beds, 65 residents a day on average. 33 citations on record from the current inspection cycles, 2 involving actual harm; 1 fine totalling $45,580.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★☆☆☆ 2 of 5 |
|---|---|
| Health inspections | ★☆☆☆☆ 1 of 5 |
| Staffing | ★★☆☆☆ 2 of 5 |
| Quality measures | ★★★★★ 5 of 5 |
| Quality: long-stay / short-stay | 4 / 5 of 5 |
Staffing
| Total nurse staffing | 3.43345 hours per resident per day |
|---|---|
| Registered nurses | 0.61953 hours per resident per day |
| Weekend total | 3.07903 hours per resident per day |
| Nursing staff turnover | 39.1% (registered nurses 42.9%) |
| Administrators who left | 0 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-06-01 complaint survey |
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0605 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-06-10 |
| 2026-06-01 complaint survey |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · tag F0690 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-06-10 |
| 2026-04-16 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Past Non-Compliance |
| 2026-02-13 | Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0691 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2026-03-19 |
| 2026-02-13 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2026-03-13 |
| 2026-02-13 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2026-03-19 |
| 2026-02-13 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · tag F0552 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-03-19 |
| 2026-02-13 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-03-13 |
| 2026-02-13 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · tag F0550 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-13 |
| 2026-02-13 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-19 |
| 2026-02-13 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0604 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-13 |
| 2026-02-13 | 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. Quality of Life and Care Deficiencies · tag F0688 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-13 |
| 2026-02-13 | Implement a program that monitors antibiotic use. Infection Control Deficiencies · tag F0881 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-13 |
| 2026-02-13 | Keep all essential equipment working safely. Environmental Deficiencies · tag F0908 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-13 |
| 2024-11-27 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2024-12-27 |
| 2024-11-27 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-12-27 |
| 2024-11-27 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · tag F0550 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-27 |
| 2024-11-27 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · tag F0558 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-27 |
| 2024-11-27 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-27 |
| 2024-11-27 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-27 |
| 2024-11-27 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-27 |
| 2024-11-27 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-27 |
| 2024-11-27 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-01-04 |
| 2024-11-27 complaint survey |
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. Pharmacy Service Deficiencies · tag F0761 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-01-04 |
| 2024-11-27 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-27 |
| 2024-08-28 complaint survey |
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0604 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-09-21 |
| 2024-08-28 complaint survey |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0607 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-09-21 |
| 2024-08-28 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-09-21 |
| 2024-08-28 complaint survey |
Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-09-21 |
| 2024-08-28 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-09-21 |
| 2023-12-22 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-01-15 |
| 2023-12-22 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-15 |
| 2023-12-22 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-15 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2026-02-13 | Fine | $45,580 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Nbh Bank Organization | 5% or greater mortgage interest | — | 2024-07-01 |
| 222 Parkview Propco LLC Organization | adp of the snf | — | 2024-07-01 |
| Advanced Care Consultants LLC Organization | adp of the snf | — | 2024-07-01 |
| Blue Management Services LLC Organization | adp of the snf | — | 2024-07-01 |
| Clinical Consulting Services LLC Organization | adp of the snf | — | 2024-07-01 |
| First Bank Of Berne Organization | adp of the snf | — | 2024-07-01 |
| Pilgrim Manor Operations Organization | adp of the snf | — | 2025-01-01 |
| Summation Financial Services LLC Organization | adp of the snf | — | 2024-07-01 |
| Adams County Memorial Hospital Organization | operational/managerial control | — | 2025-01-01 |
| Pilgrim Manor Operations Organization | operational/managerial control | — | 2025-01-01 |
| Combs, James Individual | adp of the snf | — | 2024-10-10 |
| Holm, Byron Individual | adp of the snf | — | 2024-07-01 |
| Greatorex, Tina Individual | individual is an owner, partner or trustee of any adp of the snf | — | 2025-08-06 |
| Schiowitz, Marc Individual | individual is an owner, partner or trustee of any adp of the snf | — | 2025-08-06 |
| Sebbag, Gabriel Individual | individual is an owner, partner or trustee of any adp of the snf | — | 2025-08-06 |
| Borne-Bauman, Candice Individual | managing control - governing body | — | 2024-07-01 |
| Flueckiger, Russell Individual | managing control - governing body | — | 2024-07-01 |
| Lehman, Scott Individual | managing control - governing body | — | 2024-07-01 |
| Macklin, Larry Individual | managing control - governing body | — | 2024-07-01 |
| Mcintire, David Individual | managing control - governing body | — | 2024-07-01 |
| Borne-Bauman, Candice Individual | operational/managerial control | — | 2024-07-01 |
| Combs, James Individual | operational/managerial control | — | 2024-10-10 |
| Flueckiger, Russell Individual | operational/managerial control | — | 2024-07-01 |
| Holm, Byron Individual | operational/managerial control | — | 2024-07-01 |
| Lehman, Scott Individual | operational/managerial control | — | 2024-07-01 |
| Macklin, Larry Individual | operational/managerial control | — | 2024-07-01 |
| Mcintire, David Individual | operational/managerial control | — | 2024-07-01 |
| Smith, Scott Individual | operational/managerial control | — | 2024-07-01 |
| Sprunger, Kyle Individual | operational/managerial control | — | 2024-07-01 |
| Wheeler, Dane Individual | operational/managerial control | — | 2024-07-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Pilgrim Manor.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Marshall County.