Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Shady Lane Nursing Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, limited ROM, and moderate fall risk fell out of bed after the bed became caught on a radiator and tilted at a 30-degree angle. Staff had noticed the bed was lopsided and stuck on the window sill/radiator the day before, but the issue was not reported to administration or addressed in the care plan before the resident sustained a large laceration/skin tear requiring 6 sutures.
A resident with severe cognitive impairment used a personal humidifier filled with tap water, leading to a diagnosis of Legionnaires' disease, while the facility lacked policies for humidifier use and water management. Several COVID-19 positive staff returned to work earlier than CDC guidelines allowed, and enhanced barrier precautions were not implemented for a resident with a Foley catheter, including missing signage, PPE, and proper hand hygiene during care.
A resident with severe cognitive impairment and a history of falls experienced multiple unwitnessed falls due to the facility's failure to implement timely and appropriate fall prevention interventions. Despite the resident's need for two-person assistance and inability to use a call light, only minimal interventions were added after the initial fall, and no additional measures were put in place before subsequent incidents. The DON confirmed that further interventions should have been implemented to reduce the risk of repeated falls.
A resident with moderate cognitive impairment and a diagnosis of spinal stenosis was prescribed oxycodone, but the facility did not implement or document required monitoring interventions for adverse reactions to this high-risk medication. The DON confirmed that monitoring protocols were not re-entered into the medical record when the opioid order was restarted, resulting in a lack of appropriate oversight.
Bed Caught on Radiator Led to Resident Fall With Injury
Penalty
Summary
The facility did not ensure the resident environment was free from accident hazards when a resident’s bed became caught on a radiator below the windowsill and tilted at an angle. The resident had diagnoses including age-related cognitive decline, diabetes, osteoarthritis, and edema, and a Significant Change MDS assessment showed a BIMS score of 3 out of 15, indicating severe cognitive impairment. The resident also had limited range of motion in both upper and lower extremities and required moderate staff assistance for rolling in bed. The facility’s fall risk assessment identified the resident as at moderate risk for falls. Staff documented that on the day before the fall, the resident’s bed was noticed to be tilted away from the window and toward the door, and staff pulled the bed away from the wall where it was catching on the window sill/radiator. Multiple staff statements indicated the bed had been lopsided or stuck on the window sill/radiator at times, and one staff member informed the oncoming shift to watch for it. The positioning of the bed was not reported to administration or addressed in the resident’s care plan before the fall. The next day, the resident rolled out of bed and was found on the floor beside the bed in a prone position. After the fall, the resident was sent to the ER and sustained a large laceration/skin tear to the right hand/wrist that required 6 sutures. Additional notes described injuries to the right temple and both forearms, as well as ongoing pain, swelling, bruising, and need for pain medication. The fall investigation and facility-reported incident indicated the bed was tilted at a 30-degree angle due to being caught on the radiator at the time of the fall, and staff were aware the bed had also been tilted prior to the fall.
Infection Control Failures Involving Legionella, COVID-19 Staff Return, and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, resulting in multiple deficiencies. One resident with severe cognitive impairment and a history of dementia, COPD, and stroke used a personal humidifier that was filled with tap water by staff and a family member. The facility did not have a policy or procedure for the use of humidifiers, nor did its water management program address humidifiers as a potential source for Legionella bacteria. The resident was diagnosed with Legionnaires' disease after being hospitalized for pneumonia, and subsequent investigation revealed that staff were unaware of the humidifier's presence and there was no documentation regarding its use or maintenance. The humidifier was later found to contain multiple bacteria, and water testing in the facility identified positive Legionella samples in a nearby unused whirlpool tub. The facility also failed to ensure that COVID-19 positive staff members returned to work in accordance with its own policy, which was intended to follow CDC guidelines. Review of staff records showed that several staff members returned to work earlier than recommended by the CDC, with return-to-work dates not aligning with the required isolation periods. Interviews with staff and management revealed confusion about the correct return-to-work protocols, with some staff believing a five-day isolation was sufficient, contrary to CDC guidance for healthcare personnel. Additionally, the facility did not implement enhanced barrier precautions (EBP) for a resident with an indwelling Foley catheter. There was no EBP signage or PPE cart outside the resident's room, and a CNA did not perform hand hygiene before donning gloves or wear a gown during catheter care. The CNA was unsure about the requirements for gown use during such care, and the DON confirmed that these actions were not in compliance with the facility's EBP policy.
Failure to Implement Timely Fall Interventions for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement timely and appropriate fall interventions for a resident with severe cognitive impairment and a history of falls. The resident, who had diagnoses including dementia, muscle weakness, and unsteadiness, experienced multiple unwitnessed falls over several months. After an initial fall, the only intervention added was to have the resident seen by a primary care physician, which did not occur until after a subsequent fall. No additional fall prevention measures were implemented between the first and second falls, despite the resident's inability to comprehend or use a call light and a care plan indicating the need for two-person assistance and mechanical lift for transfers. Further review showed that after each fall, interventions were added to the care plan, such as scheduled toileting and reminders not to self-transfer, but these were not implemented in a timely manner to prevent repeat incidents. The DON confirmed that no other interventions were put in place after the initial fall and acknowledged that additional measures should have been taken to reduce the risk of further falls. The lack of prompt and adequate intervention contributed to the resident experiencing repeated falls.
Failure to Monitor for Adverse Reactions to High-Risk Opioid Medication
Penalty
Summary
The facility failed to ensure that monitoring interventions for adverse reactions to a high-risk medication, specifically oxycodone, were implemented for one resident. The resident, who had a diagnosis of spinal stenosis and moderate cognitive impairment as indicated by a BIMS score of 8 out of 15, had an order for oxycodone HCl 5 mg, to be administered as half a tablet by mouth once daily. Upon review of the resident's medical record, it was found that there were no documented monitoring interventions for adverse reactions to the opioid medication, despite facility policy and current guidance requiring routine monitoring for side effects associated with high-risk medications such as opioids. The Director of Nursing (DON) confirmed during an interview that monitoring interventions for high-risk medications should be entered on the Medication Administration Record (MAR) when the medication order is transcribed. However, the DON acknowledged that the monitoring interventions were not re-entered into the resident's medical record when the oxycodone order was previously discontinued and then restarted. As a result, the resident's drug regimen was not adequately monitored for potential adverse reactions to the opioid medication.
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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 Manitowoc
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Marys Home For The Aged | 0.4 mi | ★★★★★ | 10 | 0 |
| River's Bend Health Services | 1.5 mi | ★★★★★ | 14 | 0 |
| North Ridge Health And Rehabilitation Center | 2.4 mi | ★★★★★ | 20 | 0 |
| Complete Care At Manitowoc Llc | 3.2 mi | ★★★★★ | 6 | 0 |
| Hamilton Health Services | 7.8 mi | ★★★★★ | 12 | 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 August 2026) and official state health department websites.