Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Park Manor Ltd during CMS and state inspections, most recent first.
Failure to Timely Report Alleged Abuse Incidents: The facility did not report two alleged abuse events within the required 2-hour timeframe. One resident with dementia threatened to kill his spouse and barricaded himself in the spouse’s room, causing fear, anger, and emotional harm, but the allegation was not reported to the SA on time. In another event, an RN was heard yelling at a severely cognitively impaired resident in the dining room, leaving the resident visibly upset, and the event also was not reported within the required timeframe.
Incomplete Investigation of Alleged Verbal and Psychosocial Abuse: A resident with severe cognitive impairment and a care plan addressing vulnerability to abuse was involved in an incident where an RN was reported yelling and verbally aggressive in the dining room. The resident appeared upset afterward, but the accused RN was allowed to continue working, and not all witnesses, including an LPN present during the event, were interviewed.
Failure to provide bedhold and transfer notices for multiple residents transferred to the ER/ED. Records and interviews showed that residents or their representatives were updated about transfers, but the facility could not verify that required bedhold or transfer notices were given, and some bedhold forms lacked signatures. Staff could not clearly explain the process, and residents stated they were not offered bedhold information.
The facility inaccurately coded MDS assessments for four residents, failing to reflect completed PASARR level II screenings and the use of antipsychotic medication. Despite medical records indicating the completion of PASARR level II and the prescription of Aripiprazole, these were not accurately represented in the MDS, as confirmed by the MDS Coordinator and DON.
The facility failed to develop comprehensive respiratory care plans for two residents with significant respiratory conditions. One resident had diagnoses including pneumonitis and acute respiratory failure, while the other had RSV and acute bronchiolitis. Despite having specific doctor's orders for respiratory treatments, neither resident had a comprehensive care plan addressing their respiratory needs, as confirmed by the DON during the survey.
The facility did not update care plans for two residents to reflect current care needs and interventions. One resident managed their catheter independently, contrary to the care plan, and experienced falls without updated interventions. Another resident had undocumented fall prevention measures. Staff confirmed the inaccuracies in the care plans.
A facility failed to implement enhanced barrier precautions for a resident on contact precautions. An RN entered the resident's room and performed wound care without wearing a gown, despite signage indicating the need for gown and gloves. The resident had a history of surgical amputation and required precautions to prevent infection. The RN acknowledged the oversight and corrected the action.
Failure to Timely Report Alleged Abuse Incidents
Penalty
Summary
The facility did not ensure that alleged abuse involving physical harm, pain, or mental anguish was reported immediately, and no later than 2 hours after the allegation was made to the administrator, the State Survey Agency, and other officials as required. The facility policy titled Abuse and Misconduct, last reviewed on 05/01/26, defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in mental anguish, and defines mental abuse as verbal or nonverbal conduct that causes or has the potential to cause humiliation, intimidation, fear, shame, agitation, or degradation. One incident involved R6, who had diagnoses including unspecified dementia with behavioral disturbance and a care plan addressing behavior problems and threats of harm to self or others. On 04/16/26 at 8:15 AM, staff overheard an argument between R5 and R6, during which R6 barricaded self in R5's room and threatened to kill R5. Social Worker C became aware of the allegation when staff reported it immediately, and the verbal abuse caused R5 immediate negative effects of fear, anger, and emotional harm, but the facility did not report the allegation to the SA within 2 hours. A second incident involved R8, who had severe cognitive impairment and was unable to report abuse or neglect concerns. On 06/04/25 at about 7:35-7:40 AM, CNA D heard RN E yelling at R8 in the dining room; CNA D described RN E as upset and verbally aggressive, and R8 was visibly upset afterward and kept repeating the encounter. Social Worker C acknowledged that this event should have been reported within 2 hours to the police and the SA for verbal abuse, but it was not reported within the required timeframe.
Incomplete Investigation of Alleged Verbal and Psychosocial Abuse
Penalty
Summary
The facility did not complete a thorough investigation of a reported verbal and psychosocial abuse allegation involving a resident with severe cognitive impairment and inability to complete the BIMS assessment. The resident’s care plan identified impaired cognitive function, psychosocial well-being concerns, and vulnerability to abuse, with interventions to allow time to answer questions and to follow abuse reporting procedures. On the morning of the incident, a CNA reported hearing an RN yelling in the dining room and described the RN as upset and verbally aggressive toward the resident after the resident was pounding on the table and communicating with another resident in that manner. The CNA reported that the resident appeared visibly upset afterward and kept repeating the encounter, and that another CNA and an LPN were present and witnessed the incident. The investigation was started shortly after the report, but it was not completed thoroughly. The accused RN was allowed to continue the shift after being briefly in the SW’s office, rather than being removed from the facility pending investigation. Not all present parties were interviewed, as the LPN who witnessed the incident was not interviewed. The SW acknowledged that the resident’s severe cognitive impairment and inability to report fear or negative effects meant the one-hour time frame was not enough to reach a conclusion, and acknowledged that the event should have been investigated further.
Failure to Provide Bedhold and Transfer Notices
Penalty
Summary
The facility did not provide Notice of Bedhold and Notice of Transfer to residents or resident representatives when residents were transferred from the facility to the hospital or emergency room. Record review and interviews showed this occurred for 4 of 4 residents reviewed: R4, R20, R33, and R34. The deficiency involved transfers related to changes in condition, falls, fractures, and other acute concerns, but the required documentation or notification could not be verified in the records reviewed. R4 had an activated power of attorney and was sent to the ER on multiple occasions for changes in condition. The facility contacted the APOA and left voicemail or obtained consent to send R4 to the hospital, but it could not provide documentation showing the APOA received a Notice of Bedhold or Notice of Transfer for any of the transfers reviewed. During interview, the NHA stated the facility had a performance improvement project and a discharge checklist for licensed nurses to use for discharge/transfer documentation, but also stated not all nurses had been educated on the expectations as of the survey date. R20 was cognitively intact and made his own health care decisions. The record showed transfers to the ED for a fall-related injury and later for evaluation of a T12 fracture, and a bed hold notice was present without a resident signature for one event. Nursing notes documented that the resident and daughter were aware and in agreement with transfer, but the resident stated he was not offered bed hold information. R33 and R34 were also cognitively intact or mildly impaired and made their own decisions; their records contained bed hold notices without signatures, and the facility provided progress notes showing family members were updated about transfers. Both residents stated they were not notified of bed hold, and staff interviewed could not describe the process or identify where the bed hold notice was documented.
Inaccurate MDS Coding for PASARR and Medication Use
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) 3.0 assessments for four residents, leading to discrepancies in the representation of their clinical status. Specifically, the MDS assessments for these residents incorrectly indicated that no Preadmission Screening and Resident Review (PASARR) level II was completed, despite evidence in the medical records showing otherwise. This error was identified for residents with various mental health diagnoses, including dementia, schizoaffective disorder, anxiety, and depression. The inaccuracies were acknowledged by the MDS Coordinator and the Director of Nursing during the survey. Additionally, there was an error in coding the use of high-risk drug classes for one resident. The resident was prescribed Aripiprazole, an antipsychotic, but this was not accurately reflected in the MDS assessments. The physician's orders confirmed the use of the antipsychotic, yet the MDS failed to identify it. The Director of Nursing confirmed that the expectation was for such medication use to be accurately coded in the MDS.
Lack of Comprehensive Respiratory Care Plans for Two Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for two residents, R46 and R60, specifically regarding their respiratory care needs. R46 was admitted with diagnoses including pneumonitis, sepsis, acute bronchitis, and acute respiratory failure with hypoxia. Despite having doctor's orders for medications such as budesonide and albuterol nebulizers, and mucus relief tablets, there was no specific care plan addressing R46's respiratory care. The Director of Nursing (DON) was unable to provide a comprehensive care plan for R46's respiratory needs when requested by the surveyor. Similarly, R60, who was admitted with diagnoses of Respiratory Syncytial Virus (RSV), acute bronchiolitis due to RSV, acute respiratory failure with hypoxia, and dependence on supplemental oxygen, also lacked a comprehensive respiratory care plan. R60 had doctor's orders for albuterol nebulizer, guaifenesin, and oxygen therapy, yet no specific care plan was in place. The DON confirmed the absence of a comprehensive respiratory care plan for R60 during the surveyor's inquiry.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised to reflect changes in care for two residents. Resident R45, who was admitted with a diagnosis of urinary retention and an indwelling urinary catheter, was managing the catheter independently, contrary to the care plan which stated that staff were responsible for catheter management. Additionally, R45 experienced falls, and although interventions such as wearing gripper socks and frequent checks of the catheter bag were documented, these were not updated in the care plan. Interviews with the resident, a CNA, and the DON confirmed that the care plan did not accurately reflect the resident's current care needs and interventions. Resident R6, admitted with unspecified dementia and reduced mobility, had a care plan for fall risk that included ensuring clear pathways and accessible personal items. However, observed interventions such as alarms on the bed and wheelchair, and a reminder sign on the walker, were not documented in the care plan. An LPN and the DON confirmed the absence of these interventions in the care plan, indicating a failure to update the care plan to reflect the resident's current fall prevention strategies.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions consistent with current infection control standards for a resident who was on such precautions. The deficiency was observed when a Registered Nurse (RN) entered the resident's room without donning a gown, despite the room having signage indicating the need for gown and gloves due to contact precautions. The RN proceeded to perform wound care on the resident's lower leg/stump without wearing a gown, although gloves were used. This action was contrary to the facility's policy and the standards of practice outlined by the CDC and APIC, which require the use of both gown and gloves during high-contact resident care activities to prevent the spread of multi-drug-resistant organisms (MDROs). The resident in question had a medical history that included an orthopedic aftercare following a surgical amputation, with an acquired absence of the right leg below the knee. The resident's medical record indicated the need for enhanced barrier precautions due to direct contact transmission risks. The Director of Nursing confirmed that the resident had chronic, non-healing areas on the incision line, which were not infected but required precautions to prevent infection. The RN acknowledged the oversight and corrected the action by donning a gown after being reminded of the requirement.
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What surveyors actually found near you
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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.
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Nursing homes near Park Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Careview Health And Rehab Of Minocqua | 33.3 mi | ★★★★★ | 64 | 1 |
| Villa Maria Health And Rehab Ctr | 37.4 mi | ★★★★★ | 2 | 0 |
| Sky View Nursing Center | 37.7 mi | ★★★★★ | 5 | 0 |
| Westgate Nursing & Rehabilitation Community | 38.9 mi | ★★★★★ | 5 | 0 |
| Water's Edge | 39.3 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.