Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Maryhill Manor during CMS and state inspections, most recent first.
Unsafe food storage and sanitation practices were identified when the kitchen logs for the 3-compartment sink and sanitizing buckets did not document sanitizer PPM or temperature, and the DM could not confirm staff were testing the solution as required. The surveyor also found resident food in the cooler that was improperly dated or undated, including sliced eggs, ham salad, and an open half head of cabbage, while the DM acknowledged concerns with labeling and discard timing.
Failure to Transmit Required Discharge MDS: The facility did not timely transmit a required Discharge MDS for a resident who was transferred to the hospital and did not return. Surveyors reviewed the resident’s record and MDS submissions and found no Discharge MDS had been sent. The MDSC confirmed the Discharge-Return Anticipated MDS was not completed or transmitted when the resident left the facility.
MDS assessments were inaccurately coded for three residents. One resident’s transmitted MDSs used a different first name than the resident’s legal name, another resident’s PASRR Level II showed serious mental illness but the MDS did not reflect it, and a third resident’s MDS incorrectly indicated anticoagulant use despite no current anticoagulant order or administration. The MDSC verified the coding errors in the assessments.
A resident with an intact BIMS score and a stage 2 pressure injury on the left buttock had physician orders for wound cleanser, Santyl ointment, and a Mepilex dressing, as well as a facility policy requiring no-touch technique and hand hygiene between glove changes. During an observed dressing change, an RN repeatedly failed to perform hand hygiene between glove changes, removed a soiled dressing and cleansed the wound without using clean or sterile gauze, and applied Santyl directly to the wound bed with a gloved finger instead of an applicator, before placing a new Mepilex dressing.
Two residents with orders for Enhanced Barrier Precautions (EBP) due to open wounds did not receive required PPE use during high-contact care and wound care. One resident with bilateral venous stasis ulcers and an EBP order was assisted by a CNA with toileting and transfer without any PPE, and the resident reported that staff used only gloves, not gowns or face protection, during wound care and personal hygiene. Another resident with a stage 2 buttock pressure ulcer and an EBP order received wound care from an RN who wore gloves but no gown or face shield/mask while removing a soiled dressing and cleansing the wound. The facility’s IP confirmed that gowns and gloves are required for all residents on EBP and that high-contact activities such as transfers, toileting assistance, and wound care require EBP.
A resident with severe cognitive impairment attempted to suffocate their roommate with a pillow, but the facility failed to notify the resident's physician of this significant behavioral change. The incident involved two residents with dementia and anxiety, and the oversight was acknowledged by the facility's administration.
A resident with Alzheimer's and severe cognitive impairment was involved in an altercation with a roommate, but the facility failed to update the care plan to address aggressive behavior and noise sensitivity. Despite staff moving the resident to a different room, the care plan lacked necessary interventions, as confirmed by the DON.
The facility breached confidentiality by including two residents' medical records in a former RN's personnel file, which was then shared with an outside agency. The records contained sensitive information such as diagnoses and treatment orders. The NHA was unsure of their responsibilities and did not seek permission from the residents or their representatives.
The facility failed to maintain sanitary food storage and preparation practices, affecting all residents. Staff did not document food cooling temperatures, leading to potential cross-contamination, especially concerning for a lactose-intolerant resident. Additionally, staff did not follow proper hand hygiene, using the same gloves for multiple tasks, contrary to facility policy.
A resident with a history of cerebrovascular disease, dementia, and epilepsy was not offered the PCV20 vaccine as per CDC guidelines and facility policy. The Infection Preventionist misunderstood the guidelines, believing the vaccine discussion was between the resident and their physician. The resident's Power of Attorney for Healthcare wanted the vaccine administered if the physician agreed.
A facility failed to protect residents from sexual abuse by not supervising a resident with a known history of inappropriate sexual behavior. This led to two residents being inappropriately touched by the resident. The facility did not review or act upon the resident's pre-admission documentation indicating a history of such behavior, and no monitoring interventions were in place. The incidents were not immediately reported to authorities, and staff failed to report inappropriate comments made by the resident.
The facility failed to report an allegation of sexual abuse in a timely manner to the State Agency and local law enforcement. A resident reported inappropriate touching by another resident, but the facility delayed reporting the incident, contrary to their policy requiring immediate notification. The Nursing Home Administrator did not initially report the allegation, as it was deemed unsubstantiated without completing all necessary interviews. The residents involved had moderate cognitive impairments.
A facility failed to thoroughly investigate a sexual abuse allegation between two residents, initially dismissing the claim based on limited video footage and the alleged perpetrator's denial. The investigation was only expanded after a staff member's observation led to further video review, confirming the incident. This delay resulted in a late report to the State Agency and postponed protective measures.
Unsafe Food Storage, Sanitizing Logs, and Date Marking Deficiencies
Penalty
Summary
Food was not stored and prepared in a safe and sanitary manner. During an initial kitchen tour with the Interim Dietary Manager, the surveyor reviewed the facility’s 3-compartment sink and sanitizing bucket log and found that the log contained staff initials but did not document the PPM or temperature of the sanitizing solution. The Interim Dietary Manager could not confirm whether staff tested the temperature of the sanitizing solution used in the sink and sanitizing buckets. The report also noted that the Wisconsin Food Code requires routine monitoring of sanitizing solution temperature and chemical concentration, and that the Hydrion QT-40 test strips used by the facility require the test solution to be between 65 and 75 degrees Fahrenheit. The surveyor also observed inconsistent dating and labeling of resident food in the main cooler. The cooler contained a container of sliced eggs dated 3/18, a container of ham salad dated 3/19, and an open-to-air half head of cabbage with no date. The Interim Dietary Manager later stated the facility’s previous practice was to discard all food after 3 days, but that it had recently been changed to 7 days, and acknowledged concerns with labeling and discarding food based on food safety guidelines.
Failure to Transmit Required Discharge MDS
Penalty
Summary
The facility did not ensure timely transmittal of a Resident Assessment Information/Minimum Data Set (RAI/MDS) assessment for 1 of 14 sampled residents, R23. R23 was admitted to the facility and was transferred to the hospital on 12/5/25, did not return to the facility, and a Discharge MDS assessment was not transmitted for the hospitalization. During record review of the facility’s MDS submissions, surveyors found no Discharge MDS assessment had been transmitted for R23. On 3/24/26 at 2:51 PM, the MDS Coordinator confirmed that a Discharge-Return Anticipated MDS assessment was not completed or transmitted when R23 was transferred to the hospital or when R23 did not return to the facility, and stated that it is the facility’s practice to transmit Discharge MDS assessments when residents are discharged from the facility.
MDS assessments were inaccurately coded for three residents
Penalty
Summary
The facility did not accurately code MDS 3.0 assessments for three residents. The facility’s MDS policy states residents are assessed using a comprehensive assessment process to identify care needs and develop an interdisciplinary care plan, and federal regulations require an initially and periodically comprehensive, accurate, and standardized assessment using the RAI. Survey review found that one resident’s transmitted MDS assessments were not consistently reflected under the resident’s legal first name: the Entry Tracking MDS dated 12/13/24 and Comprehensive MDS dated 12/26/24 were transmitted with a different first name than later PPS Part A Discharge, Quarterly, and Death Tracking MDS assessments. The MDS coordinator stated she was not aware the first name had been changed in the MDS system and confirmed the resident’s legal name should be used. Survey review also found coding errors for two other residents. One resident’s PASRR Level II screen dated 1/8/25 indicated the resident met the federal definition of a serious mental illness, but the Significant Change MDS dated 3/28/25 did not indicate serious mental illness; the MDS coordinator verified the assessment was coded incorrectly at Section A1500.3. Another resident’s MDS dated 3/11/26 indicated receipt of anticoagulant medication, but the resident did not have an anticoagulant order and did not receive anticoagulant medication; the resident’s MAR showed the most recent anticoagulant, enoxaparin, had been ordered for DVT prevention from 9/3/25 through 9/22/25. The MDS coordinator reviewed the assessment and verified it was coded incorrectly at Section N.
Improper Hand Hygiene and Wound Care Technique During Pressure Ulcer Treatment
Penalty
Summary
The deficiency involves failure to provide appropriate pressure ulcer care and to follow infection control practices during wound treatment for one resident. The resident had a documented stage 2 pressure injury on the left buttock, with medical orders to cleanse the wound with wound cleanser, apply a thin layer of Santyl ointment, and cover with a Mepilex padded dressing. The facility’s Clean Dressing Change policy required a no-touch technique for ointment application, use of applicators such as tongue blades, cleansing the wound as ordered, patting dry with gauze, and performing hand hygiene before donning clean gloves to apply topical treatments and dressings. During an observed wound care episode, the RN first donned gloves to wipe the resident after toileting and then removed the gloves, but did not perform hand hygiene before donning new gloves to remove the existing dressing, which contained yellow drainage. After removing those gloves, the RN again failed to cleanse hands before donning clean gloves to spray the wound with cleanser and wiped the wound with a washcloth instead of clean or sterile gauze. While wearing the same gloves, the RN used a gloved finger to remove Santyl from its container and apply it directly to the wound bed, contrary to the facility’s no-touch policy. The RN then removed the gloves, again without hand hygiene, donned new gloves, applied and dated a Mepilex dressing, and removed the gloves without cleansing hands between glove changes. The DON later confirmed that staff were expected to perform hand hygiene between glove changes and to use appropriate materials and applicators for cleansing and ointment application.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its Enhanced Barrier Precautions (EBP) policy for residents with wounds requiring high-contact care. The facility’s policy, revised 7/17/25, requires an EBP order for residents with wounds, including venous stasis ulcers and pressure ulcers, and specifies that gowns and gloves must be used for high-contact resident care activities such as dressing, bathing, transferring, toileting assistance, and wound care. The policy also requires hand hygiene before and after applying or removing PPE and before and after handling clean or soiled dressings or linens. For one resident (R1), who had diagnoses including a right femur fracture with routine healing, osteoporosis with pathological fracture, and chronic venous insufficiency with bilateral lower extremity venous stasis ulcers requiring wound care, the medical record contained an order for EBP related to vascular ulcers to both lower extremities every shift. R1 also had an order for wound care to bilateral leg ulcers twice weekly. During observation, a CNA entered and exited R1’s room without donning any PPE while assisting with toileting and a transfer. The CNA stated PPE was not worn because they believed only wound care required EBP. R1 later reported having wounds with dressings on both legs, that staff performed wound care twice weekly wearing gloves but not gowns or face shields/masks, and that staff assisted with transfers and personal hygiene without wearing gowns. For another resident (R4), who had diagnoses including a stage 2 pressure ulcer of the buttock, opioid dependence, and a non-displaced sacral fracture, the medical record contained an order for EBP related to a pressure area on the left buttock. During observation of wound care, an RN wore gloves but did not don a gown or face shield/mask while removing a dressing with yellow drainage, cleansing the wound with wound cleanser, and completing wound care. The RN confirmed that the resident was on EBP and acknowledged a gown should have been worn during wound care. The Infection Preventionist confirmed that both residents had EBP orders and that a gown and gloves are required for all residents on EBP, with face protection required when there is risk of splash, and verified that high-contact cares include bed changes, transfers, walking, toileting assistance, shaving, bathing, and wound care.
Failure to Notify Physician of Resident's Aggressive Behavior
Penalty
Summary
The facility failed to notify a physician when a resident, identified as R2, exhibited physically aggressive behavior towards another resident, R1. R2, who had a history of making threats to suffocate R1 with a pillow, attempted to place a pillow over R1's face on February 20, 2025. Despite the severity of the incident, R2's physician was not informed of this significant change in behavior, which is a requirement under the facility's Clinical Change of Condition policy. This policy mandates that any change in a resident's status should prompt an assessment and notification of the physician. R2 was admitted to the facility with diagnoses including Alzheimer's disease, dementia, and anxiety, and had a severely impaired cognition as indicated by a BIMS score of 5 out of 15. R1, who was also severely cognitively impaired with a BIMS score of 3 out of 15, was the victim of the incident. The facility's focus was on R1 as the impacted resident, and they failed to consider the necessity of notifying R2's physician about the behavioral change. This oversight was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing, who acknowledged that R2's physician should have been notified.
Failure to Update Care Plan for Resident's Aggressive Behavior
Penalty
Summary
The facility failed to ensure that a resident's care plan was reviewed and revised to address specific behavioral issues. The resident, who had diagnoses including Alzheimer's disease, dementia, psychotic disturbance, mood disturbance, and anxiety, was involved in an altercation with a roommate. The incident involved the resident placing a pillow over the roommate's head to silence them from yelling. Despite this incident, the resident's care plan was not updated to include interventions for aggressive behavior, resident-to-resident altercations, or the impact of loud noise, which was known to agitate the resident. Interviews with facility staff revealed that the resident was moved to a different room to promote safety, but there was no care plan or Kardex addressing the resident's aggressive behavior. The Director of Nursing confirmed that the care plan lacked interventions for noise reduction or providing a private room to mitigate the resident's aversion to loud noise. The failure to update the care plan was acknowledged by the facility's administration, indicating a lapse in adhering to their policy on revising care plans following changes in a resident's needs.
Confidentiality Breach of Residents' Medical Records
Penalty
Summary
The facility failed to ensure the confidentiality of medical records for two residents, R4 and R5, as part of a deficiency identified during a survey. Registered Nurse (RN)-D, after their last day of employment, requested a copy of their personnel file, which inadvertently included protected health information (PHI) from the medical records of R4 and R5. Specifically, R4's fall report and R5's Treatment Administration Record (TAR) were included in RN-D's personnel file. The fall report for R4 contained sensitive information such as age, room number, physician, diagnoses, and treatment orders, while R5's TAR included wound and behavior orders, diet orders, diagnoses, room number, physician, and date of birth. The Nursing Home Administrator (NHA)-A confirmed that RN-D's personnel file was provided to an outside government agency due to a workman's compensation claim, which included R4's fall report. However, NHA-A was uncertain about the inclusion of R5's TAR in the file. Furthermore, NHA-A admitted to not being sure of their responsibilities regarding the release of medical records and confirmed that neither R4 nor R5, nor their representatives, were informed or asked for permission to release their medical records to a former employee or an outside agency.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a sanitary manner, which had the potential to affect all 45 residents. During a kitchen tour, it was observed that staff did not monitor or document food cooling temperatures as required by the 2022 Wisconsin Food Code. Several pre-cooked and cooled foods were found in the walk-in cooler and freezer without any documentation of the cooling process. The Dietary Manager confirmed that the facility did not have a process for documenting food cooling and lacked cooling logs for the stored foods. Cross-contamination was also observed during meal service. A cook used the same scoop for different food items without cleaning it between uses, which could lead to cross-contamination. This was particularly concerning for a resident with lactose intolerance, as the same scoop was used for both regular and fortified mashed potatoes, the latter containing milk. The Dietary Manager was unaware of this practice and confirmed the potential for cross-contamination. Additionally, staff did not follow appropriate hand hygiene and safe food handling practices. Observations showed that cooks used the same gloves to handle various items, including food scoops, meal tickets, and residents' plates, without changing gloves or performing hand hygiene. This practice was against the facility's policy, which required single-use gloves or tongs for handling food. The Dietary Manager confirmed that all cooks and dietary aides were trained on appropriate hand hygiene, yet the policy was not followed during lunch service.
Failure to Offer PCV20 Vaccine to Resident
Penalty
Summary
The facility failed to ensure that a resident was offered the PCV20 vaccine as per CDC guidelines and the facility's own policy. The resident, who had a history of cerebrovascular disease, dementia, and epilepsy, was admitted to the facility and had previously received a PCV13 vaccine in 2016 and a PPSV23 vaccine in 2019. According to the CDC recommendations and the facility's policy, the resident was due to be offered the PCV20 vaccine on or after August 16, 2024. However, this was not done. The deficiency occurred because the Infection Preventionist (IP) did not offer the PCV20 vaccine to the resident, mistakenly interpreting the CDC recommendations and believing that the discussion about the vaccine should occur between the resident and their physician. The resident's Power of Attorney for Healthcare was contacted and expressed a desire for the resident to receive the PCV20 vaccine if the physician agreed. The Nursing Home Administrator expected staff to offer vaccines according to CDC recommendations and the facility's policy, but this expectation was not met in this instance.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically sexual abuse, by not adequately supervising a resident with a known history of inappropriate sexual behavior. This deficiency involved two residents, R2 and R4, who were subjected to inappropriate touching by R1. R1 had a documented history of sexually inappropriate behavior from a previous facility, which was not reviewed or acted upon by the staff at the time of R1's admission. As a result, R1 was placed in a unit with vulnerable residents without any monitoring interventions in place. On 6/6/24, R2 reported to an Activity Aide that R1 had touched R2's breast in the hallway. Initially, the Nursing Home Administrator and Director of Nursing reviewed camera footage and interviewed both residents, concluding that the allegation did not occur. However, further review of the footage revealed that R1 had indeed touched R2 inappropriately in the lounge. Additionally, another resident, R4, later reported that R1 had also touched R4's breast on a previous occasion. These incidents were not immediately reported to local law enforcement or the State Agency, and the facility did not implement monitoring interventions for R1 until after the incidents were confirmed. The facility's failure to read and act upon R1's pre-admission documentation, which indicated a history of inappropriate sexual behavior, contributed to the deficiency. Staff interviews conducted after the incidents revealed that R1 had made sexually inappropriate comments to staff members, which were not reported to administrative staff. The lack of supervision and failure to implement a care plan for R1's behavior led to a finding of immediate jeopardy, as the facility did not ensure a safe environment free from abuse for its residents.
Removal Plan
- Removed R1 from the secured dementia unit
- Initiated facility-wide education related to sexual behaviors/signs of predator
- Initiated facility-wide education related to new admissions with inappropriate behaviors
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse in a timely manner to the State Agency (SA) and local law enforcement, as required by their policy and federal regulations. On June 6, 2024, a resident (R2) reported to a staff member that another resident (R1) had touched them inappropriately without consent. Despite the facility's policy mandating immediate reporting of such allegations, the incident was not reported to local law enforcement until the following morning and to the SA later that afternoon. The facility's policy requires that allegations of abuse be reported no later than two hours after discovery or forming the suspicion. The Nursing Home Administrator (NHA) did not initially report the allegation because the facility did not substantiate it after reviewing camera footage and interviewing the involved residents. However, the NHA acknowledged that other resident and staff interviews were not completed before determining the allegation was unsubstantiated. The incident was later discovered on camera footage, prompting the facility to report the allegation to the appropriate authorities. The residents involved had moderate cognitive impairments, with R1 having a history of stroke and other medical conditions, and R2 having dementia and other diagnoses.
Inadequate Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to ensure a thorough investigation of an allegation of sexual abuse involving two residents. On June 6, 2024, a resident reported being inappropriately touched by another resident without consent. The facility's initial investigation was inadequate as it relied solely on video footage review and the denial of the alleged perpetrator, without conducting interviews with other potential witnesses or involved parties. This led to the premature dismissal of the allegation. The facility's investigation was only expanded after a staff member reported seeing the two residents together in a common area, prompting a review of additional video footage that confirmed the incident. This delay resulted in a late report to the State Agency and postponed the initiation of further investigation and protective measures. Additionally, during the subsequent investigation, another resident reported a similar incident involving the same alleged perpetrator, which had not been previously reported to staff.
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Illustrative
What surveyors actually found near you
We read the 37 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
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Nursing homes near Niagara
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Optalis Health And Rehabilitation Of Kingsford | 4.2 mi | ★★★★★ | 4 | 0 |
| Freeman Nursing & Rehabilitation Community | 4.7 mi | ★★★★★ | 5 | 0 |
| Florence Health Services | 15.5 mi | ★★★★★ | 28 | 0 |
| Pinecrest Medical Care Facility | 24.1 mi | ★★★★★ | 0 | 0 |
| Iron County Medical Care Facility | 28 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.