Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 St Marys Home For The Aged during CMS and state inspections, most recent first.
A resident with multiple complex diagnoses was discharged to an AL facility without their prescribed medications, resulting in missed doses of Parkinson's medications. The facility did not document which medications, if any, were delivered, and staff could not confirm or recall the transfer process. Communication breakdowns between the facility, pharmacy, and AL facility contributed to the deficiency.
A resident with complex medical needs did not receive restorative therapy to maintain or improve ROM and ADLs during a Medicare appeal process due to miscommunication between the therapy and social services departments. Therapy was discontinued prematurely, despite ongoing appeals, because staff believed the resident was being discharged, and there was no documentation of the decision-making process.
Unsupported Schizophrenia Diagnosis Added to Resident Record: A resident with dementia, GAD, MDD, and severe cognitive impairment had schizophrenia added to the chart and MDS, but psych notes and behavior records did not show DSM-5 criteria such as delusions, hallucinations, disorganized speech, or other required symptoms. The DON relied on a PCP note and a remote MDS nurse’s review, while the guardian stated the resident never had schizophrenia and had been stable for years under psychiatry care.
The facility failed to keep a call light within reach for a resident with severe cognitive impairment and a fall history, and failed to keep a walker positioned as directed for another resident with hemiplegia and fall risk. Staff observed the call light out of reach during multiple checks, and the walker was found away from the bedside and recliner despite care plan instructions. A CNA acknowledged the call light was forgotten, and the DON confirmed care plans should be followed.
Two residents with CPAP/BiPAP therapy did not receive proper respiratory equipment care. One resident with COPD, OSA, and severe cognitive impairment had a dirty BiPAP mask with visible debris and expired distilled water jugs in the room, while another resident with OSA had a greasy CPAP mask and dusty filter. Staff and the DON confirmed the equipment was not cleaned per manufacturer instructions, and the residents’ TARs did not include cleaning instructions for the devices or related supplies.
Infection control was not followed for three residents. A resident on droplet precautions and another on contact precautions were observed receiving care or having room tasks completed without PPE, despite signs and PPE carts being posted outside their rooms. A third resident with pneumonia was not included on the facility’s infection surveillance line list, and the DON confirmed the pneumonia diagnosis should have been documented.
A resident with a history of neurological conditions and moderate cognitive impairment experienced a significant decline in ADL function, requiring increased assistance and dietary modifications. Despite clear evidence of a major change in status, staff did not complete the required Significant Change in Status (SCIS) MDS assessment, as the responsible RN was unsure of the criteria. The facility was aware of the resident's decline, but the assessment was not performed as mandated.
A resident with moderate dementia and COPD was not offered the PCV20 vaccine as per CDC guidelines, despite being due for it since June 2022. The facility's policy requires vaccinations to be offered within two weeks of admission, but the Director of Nursing confirmed this was not done for the resident.
Failure to Reconcile and Transfer Discharge Medications
Penalty
Summary
The facility failed to ensure proper reconciliation and transfer of discharge medications for one resident who was discharged to an assisted living (AL) facility. The resident, who had complex medical needs including Alzheimer's/dementia, Parkinson's disease, anxiety, depression, congestive heart failure, and pulmonary hypertension, was discharged following a hospital stay and had an activated Power of Attorney for Healthcare. At the time of discharge, the resident did not receive their prescribed medications, and the facility did not maintain documentation of which medications, if any, were delivered to the AL facility. Interviews with the AL facility director revealed that the AL facility was unable to obtain the resident's medications from the pharmacy because they had already been filled by the nursing facility less than 30 days prior. The AL facility communicated with the nursing facility multiple times, requesting that medications be sent with the resident, but the resident arrived at the AL facility without them. The AL facility director reported that the resident missed three doses of carbidopa levodopa and one dose of amantadine, both critical for managing Parkinson's disease symptoms. Family members attempted to retrieve medications from the resident's home, and the nursing facility eventually delivered some medications the day after discharge, but there was no record of which medications were provided. Facility staff, including the social worker, nurse manager, and director of nursing, were unable to provide documentation or recall specific details regarding the transfer of medications. Pharmacy records indicated that certain medications were filled by the facility and could have been sent with the resident, but there was no confirmation or documentation of this. The nursing home administrator stated that reimbursement was offered for medication costs, but there was no documentation of this offer being communicated or received by the AL facility. The lack of documentation and communication resulted in the resident missing essential medication doses after discharge.
Failure to Provide Restorative Therapy During Medicare Appeal Process
Penalty
Summary
The facility failed to provide restorative therapy to maintain or improve range of motion (ROM) and activities of daily living (ADLs) for a resident with multiple complex medical conditions, including Alzheimer's disease, Parkinson's disease, congestive heart failure, and pulmonary hypertension. The resident had been receiving occupational, physical, and speech therapy during a rehabilitation stay, but therapy was discontinued after the facility was notified that Medicare coverage was ending and the first level appeal was denied. According to facility policy and the Notice of Medicare Non-Coverage (NOMNC), therapy services should have continued during the appeal process. However, due to miscommunication between the therapy department and social services, therapy was not continued while a second level appeal was being pursued by the resident's Power of Attorney for Healthcare (POAHC). The Therapy Director was unaware that a second level appeal was in progress and did not continue therapy, as the Social Worker did not inform the therapy department, believing the resident was being discharged to an assisted living facility. The Social Worker based this decision on a phone conversation with the POAHC and the presence of assisted living staff assessing the resident, but there was no documentation of the conversation. The resident remained in the facility for several days after therapy was stopped and did not discharge until later. The lack of communication and documentation resulted in the resident not receiving restorative therapy during the appeal period, contrary to regulatory requirements and facility policy.
Unsupported Schizophrenia Diagnosis Added to Resident Record
Penalty
Summary
The facility did not ensure that a new diagnosis of schizophrenia for one resident was supported by clinical criteria. The resident was admitted with diagnoses including dementia, generalized anxiety disorder, major depressive disorder, and insomnia due to another mental disorder. On 6/6/25, schizophrenia was added to the resident’s diagnosis list, and the care plan later referenced psychotropic medication use due to schizophrenia, although the resident’s physician orders listed trazodone for anxiety/insomnia, Abilify for depression, sertraline for generalized anxiety disorder, and donepezil for dementia, with no medication order specifically tied to schizophrenia. Survey review of the resident’s psychiatric provider notes did not show a schizophrenia diagnosis or documentation of delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or diminished emotional expression persisting for 6 months. Behavioral charting from 12/1/24 through 12/2/25 also did not document behaviors supporting schizophrenia. The resident’s MDS assessment dated 9/4/25 showed a BIMS score of 6 out of 15, indicating severe cognitive impairment, and the resident had a court-ordered guardian for decision making. The DON stated the remote MDS nurse found schizophrenia in documentation and added it to the MDS assessment, then a new PASSR was completed. When asked for supporting documentation, the DON provided a physician note signed by a PCP that listed schizophrenia, but the DON was not aware of the PCP and initially thought the visit occurred in an office rather than at the facility. The resident’s guardian stated the resident never had schizophrenia, had a prior inpatient mental health stay in 2018 related to paranoia attributed to medication changes, and had been stable for years under psychiatric care with medications that were still prescribed. The guardian also stated they were not aware of the schizophrenia diagnosis being added and did not want medication changes based on it.
Failure to Keep Call Light and Walker Within Reach for Two Residents
Penalty
Summary
The facility did not ensure the resident environment remained as free of accident hazards as possible for two residents with fall histories. R23 had diagnoses including dementia, muscle weakness, gait and mobility abnormalities, age-related physical debility, history of falling, difficulty walking, and cognitive communication deficit, and had a BIMS score of 0 out of 15 indicating severe cognitive impairment. R23’s care plan included a call light within reach with prompt response to requests, but during multiple observations R23 was in a recliner or wheelchair without a call light within reach; the easy button call light was on the nightstand or hooked to the bed and a wall call light was tucked behind the bed. A fall investigation also indicated R23 did not have access to the call light before a fall on 1/15/25, when R23 reached for a blanket, fell face forward out of the wheelchair, and sustained a bruise and abrasion to the forehead. R12, who had a diagnosis of hemiplegia and a care plan for falls related to cognitive decline and lack of safety awareness, had an intervention requiring a walker within reach at all times, at the bedside when in bed and in front of the recliner when sitting. During observations, R12 was in bed with the walker on the opposite side of the room and later was in a recliner without the walker in front of the resident. CNA-D stated the walker was not provided as required and placed it in front of R12 after being shown the care plan. The DON confirmed care plans should be followed and that R12 should have had the walker next to the resident when in bed and in the recliner.
Respiratory Equipment Not Cleaned Per Orders and Manufacturer Instructions
Penalty
Summary
The facility did not provide necessary respiratory care and services for two residents who had orders for CPAP or BiPAP therapy. One resident had diagnoses including dementia, acute and chronic respiratory failure, COPD, chronic kidney disease, pneumonia, and severe cognitive impairment with a court-ordered guardian. Surveyors observed the resident’s BiPAP machine with supplemental oxygen in the room and noted the BiPAP mask appeared dirty and greasy with white matter on the inside and outside. The resident was unsure who cleaned the BiPAP machine and supplies, and the resident’s care plan and TAR did not contain other instructions for care of the BiPAP machine or supplies. Surveyors also observed two open and partially used one-gallon jugs of distilled water next to the resident’s nightstand, both with use-by dates that had expired. The resident’s physician orders included BiPAP with oxygen at night and during naps and humidified oxygen at rest and with activity. The resident stated nursing staff filled the machine with water, but could not recall the last time the mask was cleaned and said the mask was really dirty. Surveyors observed the mask remained in the same unclean condition during repeated observations, including visible hair and dried skin particles. A second resident had OSA and a CPAP machine with a nasal mask. The resident stated staff did not clean the CPAP machine and that the resident could not complete the task independently. Surveyors observed the CPAP mask appeared greasy with white, flaky skin particles, and the filter was black with dust-like particles on the filter and inside the filter cabinet. The resident’s medical record did not contain orders for cleaning the CPAP machine, mask, tubing, or filter. The DON confirmed nurses were required to clean CPAP and BiPAP machine filters, tubes, and masks, and later confirmed both residents’ masks were not cleaned and their TARs did not contain instructions or orders for cleaning the machines, masks, tubing, or filters.
Infection Control Program Not Followed for Residents on Transmission Precautions and Surveillance
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for three sampled residents. R42 had diagnoses including quadriplegia C1-C4, spondylosis, and anxiety, a BIMS score of 5 indicating severe cognitive impairment, and an activated POAHC. The record showed R42 was diagnosed with pneumonia and was on droplet precautions, with a droplet precautions sign posted and a PPE cart outside the room. However, on two separate observations, staff entered R42's room without PPE and provided care, including speaking with the resident, removing food items, retrieving items, adjusting linens, and handling the breakfast tray. Staff interviews showed CNA-E believed PPE was no longer necessary and CNA-G stated PPE could not be applied every time staff entered the room. R11 had diagnoses including Parkinson's disease, epilepsy, falls, and UTI, a BIMS score of 9 indicating moderate cognitive impairment, and an activated POAHC. The record showed R11 was on contact precautions with a contact precautions sign and PPE cart outside the room, yet staff entered the room without PPE to adjust the call light and a housekeeper cleaned the room without PPE. Interviews showed CNA-E and HK-H did not follow the posted precautions, while the DON and NM stated staff should wear PPE for all resident care on contact precautions and when entering the room of a resident on droplet precautions. In addition, R1 had diagnoses including dementia, acute and chronic respiratory failure, and COPD, a BIMS score of 6 indicating severe cognitive impairment, and a guardian for healthcare decisions. R1 had a pneumonia diagnosis treated with antibiotics, but the resident was not listed on the facility's infection surveillance line list; the DON confirmed pneumonia should have been documented on the line list and verified staff did not add R1.
Failure to Complete Timely Significant Change MDS Assessment After Resident Decline
Penalty
Summary
A deficiency occurred when the facility failed to complete a Significant Change in Status (SCIS) Minimum Data Set (MDS) assessment in a timely manner for a resident who experienced a notable decline in condition. The resident, who had a history of traumatic subdural hemorrhage, flaccid hemiplegia, left subdural hematoma, and falls, was admitted with moderate cognitive impairment and required varying levels of assistance with activities of daily living (ADLs) as of the last MDS assessment. By mid-March, the resident's condition had declined significantly, including increased assistance needs for transfers, eating, and hygiene, as well as changes in diet and liquid consistency due to swallowing difficulties. Despite these changes, which met the criteria for a significant change in status as outlined by both CMS and the facility's own policy, the required SCIS MDS assessment was not completed. Staff interviews confirmed awareness of the resident's decline and the need for increased care, but the responsible RN did not initiate the assessment, citing uncertainty about the requirements. The Nursing Home Administrator verified that the assessment was not completed, and the resident's Power of Attorney for Healthcare also confirmed the significant decline in the resident's functional abilities.
Failure to Administer PCV20 Vaccine to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R13, was offered or administered the PCV20 vaccine as recommended by the Centers for Disease Control and Prevention (CDC) guidelines. R13, who was admitted to the facility with diagnoses including moderate dementia and chronic obstructive pulmonary disease (COPD), had previously received a PCV13 vaccine in 2015 and a Pneumococcal vaccine in 2017. According to CDC recommendations, R13 was due to receive the PCV20 vaccine by June 2022, five years after the last pneumococcal vaccine. However, the medical record review conducted by the surveyor on August 14, 2024, revealed that R13 had not been offered or administered the PCV20 vaccine since admission. During an interview on the same day, the Director of Nursing (DON) confirmed that vaccinations should be offered to residents within two weeks of admission. Despite this policy, the DON acknowledged that R13 had not been offered the PCV20 vaccine. This oversight indicates a failure in the facility's vaccination program, as outlined in their Infection Prevention and Control Manual, which mandates offering immunizations in accordance with the Advisory Committee on Immunization Practices (ACIP) recommendations.
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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) |
|---|---|---|---|---|
| Shady Lane Nursing Care Center | 0.4 mi | ★★★★★ | 4 | 0 |
| River's Bend Health Services | 1.7 mi | ★★★★★ | 14 | 0 |
| North Ridge Health And Rehabilitation Center | 2.6 mi | ★★★★★ | 20 | 0 |
| Complete Care At Manitowoc Llc | 3.3 mi | ★★★★★ | 6 | 0 |
| Hamilton Health Services | 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.