Inspection Report Summary
The most recent inspection on May 16, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies primarily involving medication management, medication storage, and Life Safety Code compliance, including issues with sprinkler maintenance and fire safety procedures. Complaint investigations substantiated some concerns about resident care, such as improper use of restraints and failure to monitor hot liquid temperatures, as well as medication documentation and storage. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows some improvement in recent visits, with the latest inspection free of cited deficiencies.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
210% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
67 residents
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 0
Date: May 16, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00454899.
Complaint Details
Complaint IN00454899 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 67
Census Bed Type: 65
Census Bed Type: 2
Census Payor Type: 4
Census Payor Type: 50
Census Payor Type: 13
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 23, 2025
Visit Reason
Paper Compliance Review to the Post Survey Revisit to the Recertification and State Licensure Survey and the Investigation of Complaint IN00442061.
Findings
Pilgrim Manor was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the Paper Compliance Review to the Post Survey Revisit to the Recertification and State Licensure Survey and Complaint survey.
Inspection Report
Re-Inspection
Census: 71
Capacity: 71
Deficiencies: 2
Date: Jan 2, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 11/27/2024, including a PSR to the Investigation of Complaints IN00442061 and IN00447285.
Complaint Details
Complaint IN00442061 was not corrected; Complaint IN00447285 was corrected.
Findings
The facility failed to ensure narcotics were counted and documented every shift, and medication carts contained loose and unlabeled medications. The facility did not implement systemic plans of correction to prevent recurrence of these deficiencies.
Deficiencies (2)
Failed to ensure narcotics were counted and documented every shift for 2 of 4 narcotic log books reviewed.
Failed to ensure medication carts were free from loose medications and failed to have medications labeled with resident identifiers during medication storage reviews for 3 of 3 medication carts observed.
Report Facts
Census: 71
Total Capacity: 71
Narcotic log missing signatures: 6
Loose pills observed: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Combs | Administrator | Signed the report |
| RN 2 | Interviewed regarding narcotic log counts and medication labeling deficiencies | |
| LPN 3 | Interviewed regarding narcotic log counts | |
| LPN 5 | Observed medication storage and loose pills on 300 hall | |
| RN 4 | Observed medication storage and loose pills on 400 hall |
Inspection Report
Annual Inspection
Census: 71
Capacity: 78
Deficiencies: 3
Date: Jan 2, 2025
Visit Reason
An annual Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) on 01/02/2025.
Findings
The facility was found not in compliance with several Life Safety Code requirements including improper placement of kitchen cooking appliances under the hood extinguishing system, lack of ground fault circuit interrupter (GFCI) protection in wet locations, and failure to complete annual inspection and testing of oxygen storage room fire door assemblies. Corrective actions were planned and implemented with audits and monitoring scheduled.
Deficiencies (3)
Failed to provide an approved method for returning cooking appliances to their approved design location under the kitchen hood extinguishing system.
Failed to ensure wet locations were provided with ground fault circuit interrupter (GFCI) protection against electric shock.
Failed to ensure annual inspection and testing of 2 oxygen storage room fire door assemblies were completed as required.
Report Facts
Certified beds: 78
Census: 71
Audit frequency: 6
Completion date: Jan 10, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Combs | Administrator | Named as facility administrator and involved in exit conference |
| Maintenance Director | Involved in observations, corrective actions, and audits related to deficiencies |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jan 2, 2025
Visit Reason
The visit was a Life Safety Code Recertification and State Licensure Survey conducted to assess compliance with fire safety and state licensure requirements.
Findings
Pilgrim Manor was found in compliance with Medicare/Medicaid participation requirements, the Life Safety Code from Fire, and applicable state regulations with no deficiencies cited.
Report Facts
Facility Number: 30
Provider Number: 155073
AIM Number: 100275260
Inspection Report
Annual Inspection
Census: 73
Capacity: 73
Deficiencies: 11
Date: Nov 27, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00447285, IN00442585, IN00442243 and IN00442061.
Complaint Details
Complaint IN00447285 - Federal deficiencies related to the allegations are cited at F684 and F689. Complaint IN00442585 - No deficiencies related to the allegation are cited. Complaint IN00442243 - No deficiencies related to the allegation are cited. Complaint IN00442061 - Federal deficiencies related to the allegations are cited at F755.
Findings
The facility was found deficient in multiple areas including resident rights, reasonable accommodations, accuracy of assessments, comprehensive care plans, quality of care, accident hazards, respiratory care, pharmacy services, medication storage, food safety, and infection prevention and control. Several residents were affected by these deficiencies, and corrective actions were planned or implemented.
Deficiencies (11)
Failed to allow residents to exercise their rights when choosing where to eat.
Failed to provide quarterly statements for residents' personal funds.
Failed to complete a timely self administration of medication assessment.
Failed to ensure comprehensive care plans were created for residents with specific medical conditions.
Failed to follow bowel movement protocols resulting in an ileus for a resident.
Failed to prevent a burn for a resident; hot liquid spilled on resident's lap.
Failed to ensure nebulizer equipment and nasal cannula tubing were stored and dated properly, and failed to provide oxygen hydration equipment.
Failed to ensure physician ordered medications were given and narcotics were counted and documented every shift.
Failed to ensure medications were stored appropriately and medication carts were free of loose pills.
Failed to ensure food was stored and prepared in a sanitary manner.
Failed to ensure enhanced barrier precautions were in place during wound care and failed to store catheter tubing and drainage bags appropriately.
Report Facts
Census: 73
Total Capacity: 73
Medicare Census: 6
Medicaid Census: 47
Other Payor Census: 20
Deficiency Count: 6
Deficiency Count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 16 | Witness to hot liquid spill incident on Resident M | |
| LPN 17 | Witness and observer of Resident M's skin condition after hot liquid spill | |
| RN 18 | Provided second opinion on Resident M's skin condition | |
| CNA 19 | Witness to hot liquid spill incident on Resident M | |
| LPN 20 | Provided information on bowel movement regimen and enhanced barrier precautions | |
| Director of Nursing | Provided multiple policies and interview responses regarding care plans, medication, and infection control | |
| Dietary Manager | Provided information on kitchen food storage and sanitation issues | |
| Administrator | Provided policy on enhanced barrier precautions |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 5
Date: Aug 28, 2024
Visit Reason
This visit was for the investigation of multiple complaints (IN00441511, IN00441555, IN00440897, IN00440753, IN00439878, and IN00441571) related to Pilgrim Manor.
Complaint Details
The investigation was triggered by complaints IN00441511, IN00441555, IN00440897, IN00440753, IN00439878, and IN00441571. Deficiencies were cited related to complaints IN00441511 and IN00441555. Complaints IN00440897, IN00440753, IN00439878, and IN00441571 had no deficiencies related to the allegations.
Findings
The facility was found deficient in multiple areas including improper use of physical restraints on Resident C, failure to report and investigate abuse allegations properly, and failure to monitor hot liquid temperatures leading to burns on Resident B. Several complaints were substantiated with cited deficiencies, while others had no deficiencies related to the allegations.
Deficiencies (5)
Failed to ensure 1 of 1 residents reviewed for restraints were free from physical restraints (Resident C tied to wheelchair with a sheet).
Failed to implement abuse policy when staff failed to report an allegation of abuse regarding an alleged use of a physical restraint (Resident C).
Failed to report to the State Agency an allegation of abuse for 1 of 3 residents reviewed for abuse (Resident C).
Failed to ensure a thorough investigation was completed for an allegation of abuse for 1 of 3 residents reviewed for abuse (Resident C).
Failed to monitor temperatures of coffee and hot water before serving fluids and failed to assess a resident for hot fluid safety, resulting in second degree burns (Resident B).
Report Facts
Census: 69
SNF/NF Census: 64
SNF Census: 5
Medicare Census: 11
Medicaid Census: 34
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee 4 | Named in physical restraint finding for tying Resident C to wheelchair with a sheet; no longer employed. | |
| Employee 5 | Named in physical restraint finding for tying Resident C to wheelchair with a sheet and failure to report incident. | |
| Employee 13 | Reported knowledge of restraint incident and Director of Nursing awareness. | |
| Employee 16 | Reported observation of Resident C tied to wheelchair with sheet. | |
| Administrator | Administrator | Received reports of restraint incident, reviewed video footage, acknowledged failure to investigate and report abuse allegations properly. |
| Director of Nursing | Director of Nursing | Interviewed regarding restraint incident, had knowledge of incident but failed to report properly. |
| Employee 23 | Provided care to Resident B and described incident of hot tea spill. | |
| Employee 22 | Kitchen Staff | Reported no prior temperature checks of hot liquids before recent changes. |
| Dietary Manager | Dietary Manager | Reported on hot liquid temperature monitoring and incident involving Resident B. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 28, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaints IN00441511 and IN00441555.
Complaint Details
The visit was related to complaints IN00441511 and IN00441555, and the facility was found to be in compliance.
Findings
Pilgrim Manor was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 regarding the paper compliance review of the complaint investigation.
Inspection Report
Follow-Up
Census: 55
Capacity: 78
Deficiencies: 0
Date: Feb 27, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 01/17/24 was conducted by the Indiana Department of Health in accordance with 42 CFR Subpart 483.90(a).
Findings
At this Life Safety Code PSR, Pilgrim Manor was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered in all resident access areas and had appropriate fire alarm and smoke detection systems.
Report Facts
Certified beds: 78
Census: 55
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 0
Date: Feb 19, 2024
Visit Reason
This visit was conducted for the investigation of two complaints, IN00428452 and IN00427878.
Complaint Details
Complaint IN00428452 and Complaint IN00427878 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in either complaint were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF: 53
Census SNF: 5
Total Census: 58
Census Medicare: 3
Census Medicaid: 36
Census Other: 19
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 12, 2024
Visit Reason
The document reports on paper compliance to the investigation of Complaint Number IN00426717 conducted on 2024-01-22, with completion on 2024-02-12.
Complaint Details
Investigation of Complaint Number IN00426717 conducted on 2024-01-22; paper compliance completed on 2024-02-12.
Findings
Pilgrim Manor was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies, and 410 IAC 16.2.
Inspection Report
Complaint Investigation
Census: 53
Capacity: 78
Deficiencies: 2
Date: Jan 22, 2024
Visit Reason
The inspection was conducted as an investigation of Complaint Number IN00426717 by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Complaint Details
Complaint Number IN00426717 was substantiated. The complaint involved failure to comply with fire safety requirements including sprinkler system impairment and fire alarm response.
Findings
The facility was found not in compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the Life Safety Code. Deficiencies included failure to properly conduct fire watches during sprinkler system impairment and failure to properly respond to fire alarm activations.
Deficiencies (2)
Failed to properly conduct fire watches when the automatic sprinkler system was out-of-service for 10 hours or more, with inadequate training and documentation of fire watch personnel.
Failed to properly respond to activation of the fire alarm system, including inadequate knowledge and response procedures by staff.
Report Facts
Certified beds: 78
Census: 53
Fire watch rounds: 2
Sprinkler system out-of-service duration: 10
Plan of correction completion date: Feb 12, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori Smith | Administrator | Present during survey and involved in interviews regarding fire watch and fire safety plan |
Inspection Report
Life Safety
Census: 54
Capacity: 78
Deficiencies: 3
Date: Jan 17, 2024
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101, Life Safety Code.
Findings
The facility was found not in compliance with Life Safety Code requirements due to deficiencies in sprinkler system maintenance and testing, corrosion on a sprinkler head, and lack of ground fault circuit interrupter (GFCI) protection on electrical outlets near wet locations.
Deficiencies (3)
Failed to maintain 1 of 2 automatic sprinkler systems in accordance with NFPA 25; sprinkler heads dated 1969 due for testing, with 1 of 4 sample tested heads failed.
Failed to replace 1 corroded sprinkler head in an area with moisture, violating NFPA 25 requirements.
Failed to ensure ground fault circuit interrupter (GFCI) protection for 1 of 1 wet locations in the main dining room near the sink.
Report Facts
Certified beds: 78
Census: 54
Sprinkler heads to be replaced: 146
Sprinkler heads replaced as of 01/30/24: 40
Residents potentially affected by corroded sprinkler head: 15
Outlets near water inspected monthly: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Byron M. Holm | Medical Director | Reviewed the 2567 and Plan of Correction |
| Lori A. Smith | Administrator | Named in relation to exit conference and report signature |
Inspection Report
Renewal
Census: 57
Deficiencies: 3
Date: Dec 22, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from December 18 to December 22, 2023.
Findings
The facility was found deficient in developing comprehensive care plans for residents at risk of aspiration and pressure ulcers, preventing pressure ulcers caused by medical devices, and maintaining sanitary food storage and serving practices. Plans of correction and audits were implemented to address these deficiencies.
Deficiencies (3)
Failed to develop a care plan for a resident with aspiration/choking risk and a resident with a pressure ulcer for 2 of 19 residents reviewed for comprehensive care plans.
Failed to prevent the development of a pressure ulcer from a medical device for 1 of 3 residents reviewed for pressure ulcers.
Failed to store and serve food under sanitary conditions related to open and undated dry goods and touching the eating surface of salad bowls with bare hands.
Report Facts
Survey dates: 5
Census: 57
Residents reviewed for comprehensive care plans: 19
Residents reviewed for pressure ulcers: 3
Residents identified with medical devices: 11
Residents at risk for aspiration or choking: 11
Pressure ulcer stage 2 size: 2.5
Pressure ulcer stage 2 size: 3.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori A. Smith | Administrator | Signed report and contact for plan of correction |
| Byron M. Holm | Medical Director | Reviewed the 2567 and Plan of Correction |
| Director of Nursing | Interviewed regarding care plan deficiencies and medical device skin checks | |
| RN 3 | Registered Nurse | Interviewed about care plan specifics for pressure ulcer |
| Activities Assistant 2 | Observed touching eating surfaces of salad bowls |
Inspection Report
Renewal
Deficiencies: 0
Date: Dec 22, 2023
Visit Reason
The inspection was conducted as a Paper Compliance Review to the Recertification and State Licensure Survey.
Findings
Pilgrim Manor was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the Paper Compliance Review for Recertification and State Licensure Survey.
Inspection Report
Life Safety
Census: 57
Capacity: 78
Deficiencies: 4
Date: Mar 6, 2023
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Findings
The facility was found not in compliance with several Life Safety Code requirements including failure to maintain spare sprinkler heads properly, lack of electrically supervised smoke detection in one activity room, improper installation of sprinkler escutcheon plates, and a sprinkler head covered with dirt and lint. Corrective actions were planned and discussed with facility leadership.
Deficiencies (4)
Failed to ensure spare sprinklers, a large enough sprinkler cabinet, and a sprinkler wrench were maintained on premises.
Failed to provide electrically supervised automatic smoke detection system in 1 of 2 activity rooms open to the corridor.
Failed to maintain ceiling construction around sprinkler heads with dislodged escutcheon plates in 1 of 5 smoke compartments.
Failed to ensure 1 of 15 sprinkler heads was free from dirt and lint loading.
Report Facts
Certified beds: 78
Census: 57
Sprinkler heads with dislodged escutcheon plates: 4
Activity room residents/staff potentially affected: 15
Residents potentially affected by sprinkler head dirt: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori A. Smith | Administrator | Named in plan of correction and exit conference |
| Maintenance Director | Interviewed and involved in findings related to sprinkler system and smoke detection |
Inspection Report
Life Safety
Deficiencies: 0
Date: Mar 6, 2023
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey was conducted on 03/06/23 and completed on 03/29/23.
Findings
Pilgrim Manor was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Annual Inspection
Census: 58
Capacity: 58
Deficiencies: 6
Date: Feb 15, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00397354.
Complaint Details
Complaint IN00397354 was substantiated with Federal/State deficiencies cited at F686, F692, and F693.
Findings
The facility was found deficient in multiple areas including failure to follow care plans for range of motion, pain management, pressure ulcer prevention and treatment, nutrition and hydration via tube feeding, psychotropic medication monitoring, and medication storage and labeling.
Deficiencies (6)
Failed to follow care plans for range of motion for 2 of 23 residents reviewed.
Failed to follow Physician's Orders for administration of morphine for 1 of 1 residents reviewed for pain management.
Failed to ensure physician orders and care plan interventions for pressure ulcer were followed for 1 of 4 residents reviewed for pressure ulcers.
Failed to ensure a resident who is fed by a tube received the physicians' ordered tube feeding to maintain her weight for 1 of 3 residents reviewed for nutrition.
Failed to adequately monitor side effects and behaviors for 3 out of 5 residents that took psychotropic medications.
Failed to ensure medication storage areas were free from medications with no resident identifiers, free from expired glucose control solutions, medications were dated when opened, and intravenous supplies did not remain in the facility after the resident had expired.
Report Facts
Census: 58
Total Capacity: 58
Residents reviewed for ROM care plans: 23
Residents on morphine: 4
Residents on psychotropic medications: 30
Weight loss: 5.6
Weight loss percentage: 5.58
Tube feeding volume not received: 922.68
Tube feeding volume not received: 393.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori Smith | Administrator | Named in relation to plan of correction and policy provision. |
| RN 5 | Observed wound care dressing change for Resident B. | |
| CNA 17 | Provided information about restorative program and resident positioning. | |
| RN 6 | Administered medications and managed tube feeding for Resident B. | |
| QMA 17 | Observed medication storage issues with turmeric and glucose solution. | |
| QMA 15 | Observed undated morphine bottle in medication cart. | |
| LPN 19 | Observed intravenous supplies for non-current resident. | |
| Director of Nursing | Provided interviews regarding pain management and psychotropic medication monitoring. | |
| Unit Manager | Provided interview regarding psychotropic medication monitoring. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 15, 2023
Visit Reason
Paper Compliance to the Recertification and State Licensure Survey and Complaint Investigation for IN00397354.
Findings
Pilgrim Manor was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the Paper Compliance Review to the Recertification and State Licensure Survey and Complaint Investigation.
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