Public Record
Pilgrim Manor
From CMS
Facility profile
- CMS overall rating
- 2 / 5
- Certified beds
- 78
- Avg. residents per day
- 64.3
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 55
- Inspections on file
- 10
- Last inspection
- 2026-02-13
*CMS
*CMS
*CMS
Citations
55 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0351Generalpotential for harm
Install an approved automatic sprinkler system.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0552Generalpotential for harm
Ensure that residents are fully informed and understand their health status, care and treatments.
- 0580Generalpotential for harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 0604Generalpotential for harm
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
- 0688Generalpotential for harm
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.
- 0691Seriousactual harm
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0041Generalpotential for harm
Implement emergency and standby power systems.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0881Generalpotential for harm
Implement a program that monitors antibiotic use.
- 0908Generalpotential for harm
Keep all essential equipment working safely.
- 0914Generalpotential for harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- 0761Generalpotential for harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0511Generalpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0923Generalpotential for harm
Have proper medical gas storage and administration areas.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0558Generalpotential for harm
Reasonably accommodate the needs and preferences of each resident.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0684Seriousactual harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0761Generalpotential for harm
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.
- 0324Generalpotential for harm
Provide properly protected cooking facilities.
- 0511Generalpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0604Generalpotential for harm
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0607Generalpotential for harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- 0711Generalpotential for harm
Provide a written emergency evacuation plan.
- 0354Generalpotential for harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- 0511Generalpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 0693Generalpotential for harm
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.
- 0758Generalpotential for harm
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.
- 0761Generalpotential for harm
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.
- 0351Generalpotential for harm
Install an approved automatic sprinkler system.
- 0361Generalpotential for harm
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ
Questions and answers
- What is Pilgrim Manor?
- Pilgrim Manor is a Medicare- and Medicaid-certified nursing home in Plymouth, IN, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 155073.
- What is the CMS rating for Pilgrim Manor?
- Pilgrim Manor has a CMS overall rating of 2 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Pilgrim Manor have?
- Pilgrim Manor is certified for 78 beds. It serves an average of 64.3 residents per day.
- How many citations does Pilgrim Manor have?
- Pilgrim Manor has 55 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Pilgrim Manor last inspected?
- Pilgrim Manor was last inspected on February 13, 2026. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
/nursing-home/155073-pilgrim-manor