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The Overall CMS Rating is scored from 1 to 5 stars and combines results from health inspections, staffing levels, and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
The Overall CMS Rating is scored from 1 to 5 stars and combines results from health inspections, staffing levels, and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
The Overall CMS Rating combines results from health inspections, staffing levels and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
Based on the results of the facility's three most recent standard inspections and any complaint investigations. CMS reviews the number, scope, and severity of deficiencies, with more recent findings weighted more heavily.
Measures average nursing staff hours per resident per day, including Registered Nurses (RNs) and total nursing staff. Ratings are adjusted based on the level of care residents require and are compared to state and national benchmarks.
Based on clinical and physical health indicators reported to CMS, such as hospital readmissions, falls, pressure ulcers, and improvements in mobility. These measures reflect how well residents' health needs are being managed.
Daily nursing hours per resident by staff type, reported to CMS. Higher is generally better — compare this facility to state and national averages to see where staffing stands.
This home is ranked 128th out of 287 homes in Indiana. Total adjusted nursing hours per resident per day, combining RN, LPN, and aide time. CMS adjusts this for case-mix so facilities can be fairly compared.
| Staff type | Hours / Day / Resident | vs state avg |
|---|---|---|
|
Registered Nurse (RN)
RNs hold the highest nursing license and can assess residents, interpret test results, and direct care plans. More RN hours per day often signals stronger clinical oversight and faster response to health changes.
| 49m per day | ▲ 17% State avg: 42m per day · National avg: 41m per day |
|
LPN / LVN
Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) deliver routine hands-on care — medication administration, wound dressing, and monitoring vital signs. They work under RN supervision and make up a large share of daily bedside care.
| 42m per day | ▼ 16% State avg: 50m per day · National avg: 52m per day |
|
Nurse Aide
Certified Nurse Aides (CNAs) provide the most direct day-to-day assistance: bathing, dressing, feeding, and mobility. Nurse aide hours are typically the largest staffing category and directly affect residents' quality of life.
| 2h 27m per day | ▲ 7% State avg: 2h 17m per day · National avg: 2h 20m per day |
|
Weekend Total Nursing
Combined nursing hours (RN + LPN + Nurse Aide) per resident per day on weekends. Staffing often drops on weekends — this figure reveals whether the facility maintains adequate coverage outside of weekday hours.
| 3h 1m per day | ▼ 12% State avg: 3h 25m per day · National avg: 3h 26m per day |
|
Physical Therapist
Hours per resident per day provided by licensed Physical Therapists (PTs) or PT Assistants. PT services help residents recover mobility after injury or illness and are especially important for post-acute (short-stay) rehabilitation.
| 4m per day | ▼ 20% State avg: 5m per day · National avg: 4m per day |
|
Weekend RN
Registered nurse hours specifically on weekends. Facilities sometimes reduce RN presence on Saturdays and Sundays — a low weekend RN figure compared to weekday hours can indicate reduced clinical oversight when most administrative staff are absent.
| 36m per day | ▲ 29% State avg: 28m per day · National avg: 28m per day |
Higher than the Indiana average: 68.1%Pilgrim Manor is legally operated by Adams County Memorial Hospital, and administrated by James Combs.
Key information about the people who lead and staff this community.
In Indiana, the Department of Health, Division of Long Term Care is the primary regulatory body that performs onsite inspections and quality of care reviews for all licensed facilities.
This scorecard compares key inspection, citation, and complaint metrics at this facility against the Indiana state average. Metrics rated ≥15% worse than average are highlighted in red; those ≥15% better are highlighted in green.
Deficiencies
| This Facility | IN Average | vs. IN Avg |
|---|---|---|---|
|
Total deficiencies
Formal regulatory issues recorded by inspectors across all inspection types.
| 39 | 36 | This facility has 8% more total deficiencies than a typical Indiana nursing home (39 vs. IN avg 36).↑ 8% worse |
|
Deficiencies per year
Average deficiencies per year since 2023.
| 13 | 12 | This facility has 8% more deficiencies per year than a typical Indiana nursing home (13 vs. IN avg 12).↑ 8% worse |
|
Deficiencies per inspection
Average deficiencies per inspection.
| 2.1 | 1.9 | This facility has 11% more deficiencies per inspection than a typical Indiana nursing home (2.1 vs. IN avg 1.9).↑ 11% worse |
Inspections
| This Facility | IN Average | vs. IN Avg |
|---|---|---|---|
|
Total visits
Combined count of all on-site visits — routine inspections, complaint visits, follow-ups, and other focused visits.
| 19 | 19 | This facility has total visits in line with the Indiana average (19 vs. IN avg 19).— At avg |
|
Inspections with deficiencies
Inspections that resulted in at least one regulatory deficiency.
| 9 | 7 | This facility has 29% more inspections with deficiencies than a typical Indiana nursing home (9 vs. IN avg 7).↑ 29% worse |
|
Inspection deficiency rate
Percentage of inspections that resulted in at least one deficiency.
| 47% | 37% | This facility has 10 percentage points higher inspection deficiency rate than a typical Indiana nursing home (47% vs. IN avg 37%).↑ 10% worse |
|
Inspections
Routine, scheduled inspections conducted by state regulators.
| 11 | 13 | This facility has 15% fewer inspections than a typical Indiana nursing home (11 vs. IN avg 13).↓ 15% better |
Complaints & Investigations
| This Facility | IN Average | vs. IN Avg |
|---|---|---|---|
|
Total complaints
Formal expressions of concern made by residents, families, or staff.
| 5 | 5 | This facility has total complaints in line with the Indiana average (5 vs. IN avg 5).— At avg |
|
Complaints per year
Average complaints per year since 2023.
| 1.7 | 1.7 | This facility has complaints per year in line with the Indiana average (1.7 vs. IN avg 1.7).— At avg |
An editor-reviewed summary of the themes and findings across this facility's recent inspection reports.
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.
Read the full inspection reports for this facility, including detailed findings and corrective actions.
Show Inspection ReportsIndiana average 6
Last Health inspection on Nov 2024
Indiana average 25
Indiana average 4.12
Health citations are formal notices following inspections when they fail to comply with safety and care standards.
15 of 26 citations resulted from standard inspections; 5 of 26 resulted from complaint investigations; and 6 of 26 came from combined inspections (standard and complaint).
100% better than Indiana averageIndiana average: 0.2
67% worse than Indiana averageIndiana average: 0.6
Corrected
Corrected
Corrected
Corrected
Reporting period: October 1 – December 31, 2025 (Q4 2025). Source: CMS Payroll-Based Journal report.
1386567% better than Indiana average
6% worse than Indiana average
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
Manages medical care and health needs.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
7.9 hoursThis role is partially covered by contractors.
Assists with medical care and medications.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
7.7 hoursThis role is partially covered by contractors.
Helps with daily care and mobility.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
7.2 hoursThis role is partially covered by contractors.
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
Total hours from contractors
741 contractor hours this quarter
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
| Certified Nursing Assistant | 42 | 1 | 43 | 10,021 | 92 | 100% | 7.2 |
| Medication Aide/Technician | 11 | 0 | 11 | 3,493 | 92 | 100% | 7.2 |
| Registered Nurse | 13 | 3 | 16 | 2,799 | 92 | 100% | 7.9 |
| Licensed Practical Nurse | 6 | 5 | 11 | 2,119 | 92 | 100% | 7.7 |
| Clinical Nurse Specialist | 2 | 0 | 2 | 962 | 64 | 70% | 7.9 |
| RN Director of Nursing | 2 | 0 | 2 | 952 | 64 | 70% | 8 |
| Other Dietary Services Staff | 2 | 0 | 2 | 946 | 86 | 93% | 8 |
| Physical Therapy Assistant | 3 | 0 | 3 | 609 | 64 | 70% | 6.1 |
| Therapeutic Recreation Specialist | 3 | 0 | 3 | 523 | 64 | 70% | 5.7 |
| Administrator | 1 | 0 | 1 | 480 | 60 | 65% | 8 |
| Dietitian | 1 | 0 | 1 | 472 | 59 | 64% | 8 |
| Mental Health Service Worker | 1 | 0 | 1 | 456 | 57 | 62% | 8 |
| Nurse Practitioner | 1 | 0 | 1 | 440 | 55 | 60% | 8 |
| Respiratory Therapist | 1 | 0 | 1 | 428 | 73 | 79% | 5.9 |
| Respiratory Therapy Technician | 2 | 0 | 2 | 151 | 45 | 49% | 3.3 |
| Occupational Therapy Aide | 0 | 2 | 2 | 133 | 24 | 26% | 5.5 |
| Qualified Social Worker | 1 | 0 | 1 | 124 | 39 | 42% | 3.2 |
| Medical Director | 0 | 1 | 1 | 40 | 24 | 26% | 1.6 |
Federal penalties imposed by CMS for regulatory violations, including civil money penalties (fines) and denials of payment for new Medicare/Medicaid admissions.
Source: CMS Penalties Database
No penalties in the past 3 years
No civil money penalties or payment denials were reported in the last 3 years.
These measures show how residents usually do over time at this home, based on health outcomes and preventive care.
A composite score based on pressure ulcers, falls with injury, weight loss, walking ability decline, and activities of daily living decline.
14.5
81% worse than Indiana averageIndiana average: 8.0
A composite score based on activities of daily living decline, walking ability decline, and incontinence.
28.9
70% worse than Indiana averageIndiana average: 17.1
CMS star rating based on long-stay quality measure performance. 5 stars = significantly above average, 1 star = significantly below average.
Percent of long-stay residents whose need for help with daily activities has increased
28.4%
135% worse than Indiana averageIndiana average: 12.0%
Percent of long-stay residents whose ability to move independently worsened
27.5%
92% worse than Indiana averageIndiana average: 14.4%
Percent of low risk long-stay residents who lose control of their bowels or bladder
30.9%
26% worse than Indiana averageIndiana average: 24.6%
Percent of long-stay residents experiencing one or more falls with major injury
3.7%
5% better than Indiana averageIndiana average: 3.9%
Percent of long-stay high risk residents with pressure ulcers
4.1%
6% better than Indiana averageIndiana average: 4.4%
Percent of long-stay residents with a urinary tract infection
3.7%
201% worse than Indiana averageIndiana average: 1.2%
Percent of long-stay residents who lose too much weight
8.9%
57% worse than Indiana averageIndiana average: 5.7%
Percent of long-stay residents who have depressive symptoms
6.6%
73% better than Indiana averageIndiana average: 24.1%
Percent of long-stay residents who received an antipsychotic medication
4.7%
63% better than Indiana averageIndiana average: 12.4%
Percent of long-stay residents assessed and appropriately given the pneumococcal vaccine
93.1%
In line with Indiana averageIndiana average: 93.7%
Percent of long-stay residents assessed and appropriately given the seasonal influenza vaccine
97.1%
In line with Indiana averageIndiana average: 95.4%
Number of hospitalizations per 1,000 long-stay resident days.
1.12
47% better than Indiana averageIndiana average: 2.10
Number of outpatient emergency department visits per 1,000 long-stay resident days.
0.14
91% better than Indiana averageIndiana average: 1.53
CMS star rating based on short-stay quality measure performance. 5 stars = much above average, 1 star = much below average.
Percent of short-stay residents assessed and appropriately given the pneumococcal vaccine
68.2%
17% worse than Indiana averageIndiana average: 81.7%
Percent of short-stay residents who newly received an antipsychotic medication
0.8%
42% better than Indiana averageIndiana average: 1.4%
Percent of short-stay residents assessed and appropriately given the seasonal influenza vaccine
79.2%
In line with Indiana averageIndiana average: 79.0%
Percentage of short-stay residents who were re-hospitalized after their nursing home admission.
25.1%
In line with Indiana averageIndiana average: 25.0%
Percentage of short-stay residents who had an outpatient emergency department visit.
8.6%
23% better than Indiana averageIndiana average: 11.1%
Percentage of SNF residents who experience falls with major injury during their stay.
1.8%
136% worse than Indiana averageIndiana average: 0.8%
Percentage of residents at or above expected ability to care for themselves at discharge.
54.9%
In line with Indiana averageIndiana average: 53.7%
Rate of successful return to home or community from a skilled nursing facility.
58.4%
15% better than Indiana averageIndiana average: 50.6%
Quality measures are calculated from Minimum Data Set (MDS) assessments. For most measures, lower percentages indicate better care quality.
54% of new residents, usually for short-term rehab.
35% of new residents, often for short stays.
12% of new residents, often for long-term daily care.
Source: CMS Long-Term Care Facility Characteristics (Data as of Jan 2026)
Total residents
75Residents meet regularly to discuss policies, care quality, and activities
Organized group of residents that meets regularly to discuss facility policies, quality of life, and activities.
Data sourced from CMS Long-Term Care Facility Characteristics quarterly report. Payer mix reflects the current resident census by primary payment source.
Historical financial and operational data for Pilgrim Manor based on CMS SNF Cost Reports.
The portion of the home's budget spent on staff, including nurses, caregivers, and other employees who support care and operations.
Rank #269 / 290Payroll — State benchmarkedThis home is ranked 269th out of 290 homes in Indiana. Shows total annual staff payroll benchmarked to the Indiana average. Higher payroll investment relative to peers often signals better staffing and less reliance on cheaper contract labor.Click the rank badge to see the full State ranking.Click here to see the full State ranking.
All remaining costs needed to run the home, such as food, utilities, building maintenance, supplies and administrative expenses.
Most residents typically stay for a few weeks or months before returning home or moving on.
0.0 miles from city center
Estimated distance in miles from Plymouth's city center to Pilgrim Manor's address, calculated via Google Maps.
Add your location
Pilgrim Manor is located in PLYMOUTH, Indiana.
Here are the financial assistance programs available to residents in Indiana.
The information below is reported by the Indiana Department of Health, Division of Long Term Care.
| North River Health Campus |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence.
IL Independent Living Lifestyle-focused communities for older adults offering dining, activities, and transportation with minimal personal care. Best for active, independent seniors who want community without medical support.
MC Memory Care Secured, specialized care for people living with Alzheimer's or dementia. Staff trained in cognitive impairment, with higher staff-to-resident ratios and an environment designed to reduce confusion and wandering risk. | Evansville (East Baseline Road) | 95 | 50.5% | -27% | 3.66 | +63% | +7% | $3.3k | 10 | 3.3 | - | 47 | A+ | 11 | Thomas Cook | $12.0M | $6.4M | 53.4% | 155854 | ||||
| Greenwood Village South |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence.
IL Independent Living Lifestyle-focused communities for older adults offering dining, activities, and transportation with minimal personal care. Best for active, independent seniors who want community without medical support.
MC Memory Care Secured, specialized care for people living with Alzheimer's or dementia. Staff trained in cognitive impairment, with higher staff-to-resident ratios and an environment designed to reduce confusion and wandering risk. | Greenwood | 207 | 18.4% | -73% | 4.16 | -50% | +21% | $0 | 6 | 3.0 | - | 38 | A+ | 50 | Pamela Seegers | $35.6M | $17.6M | 49.4% | 155026 | ||||
| West River Health Campus |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence.
MC Memory Care Secured, specialized care for people living with Alzheimer's or dementia. Staff trained in cognitive impairment, with higher staff-to-resident ratios and an environment designed to reduce confusion and wandering risk. | Evansville (Westside) | 131 | 74.0% | +7% | 4.56 | -1% | +33% | $18.7k | 17 | 2.1 | 2 | 97 | A+ | 2 | Carla Baker | $11.1M | $5.9M | 53% | 155785 | ||||
| Westside Garden Plaza |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence.
IL Independent Living Lifestyle-focused communities for older adults offering dining, activities, and transportation with minimal personal care. Best for active, independent seniors who want community without medical support.
MC Memory Care Secured, specialized care for people living with Alzheimer's or dementia. Staff trained in cognitive impairment, with higher staff-to-resident ratios and an environment designed to reduce confusion and wandering risk.
IL Independent Living Lifestyle-focused communities for older adults offering dining, activities, and transportation with minimal personal care. Best for active, independent seniors who want community without medical support. | Indianapolis (Chapel Hill / Ben Davis) | 150 | 47.3% | -32% | 3.49 | -29% | +1% | $0 | 76 | 6.9 | 1 | 71 | A+ | 10 | Westside Snf Operations LLC | $14.1M | $7.0M | 49.9% | 155606 | ||||
| Pilgrim Manor |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence. | Plymouth | 78 | 85.9% | +24% | 3.42 | +57% | 0% | $0 | 26 | 6.5 | 1 | 65 | - | 83 | Adams County Memorial Hospital | $3.2M | $2.5M | 77.8% | 155073 |
Connie Bennett is the Director of Nursing at Pilgrim Manor.
The legal owner and operator of Pilgrim Manor is Adams County Memorial Hospital.
Pilgrim Manor has a walk score of 83. Very walkable. Most errands can be accomplished on foot, and many essentials are within a short walk.
According to IN state health department records, Pilgrim Manor's license number is 25-000030-1.
According to IN state health department records, Pilgrim Manor's license expires on June 30, 2026.
Pilgrim Manor's occupancy is 86%.
James Combs is the administrator of Pilgrim Manor.
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