Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Manitowoc Llc during CMS and state inspections, most recent first.
A resident with a history of stroke and other chronic conditions was assessed by an RN for possible stroke symptoms after a friend raised concerns, but the RN did not document the neurological assessment in the medical record at the time of service. The missing documentation was only entered after the DON requested it, contrary to facility policy requiring timely and accurate recordkeeping.
Two residents in an LTC facility were found with catheter drainage bags in contact with the floor, contrary to the facility's policy. The bags were uncovered, increasing the risk of infection. Staff interviews confirmed the bags should be hung from the bed and covered, indicating a lapse in proper catheter care practices.
A resident on a consistent carbohydrate (CCHO) diet was served an incorrect meal, including a full piece of pie and a dinner roll, contrary to their meal ticket. The Dietary Aide responsible was not familiar with CCHO diets, despite the Culinary Director's assertion that training had been provided. The issue was confirmed by the Culinary Director and Registered Dietitian.
The facility failed to adhere to infection control protocols, as staff did not use PPE during a resident transfer under Enhanced Barrier Precautions, and a Dietary Aide neglected hand hygiene after handling a garbage can. The resident had Alzheimer's, dementia, diabetes, and a pressure ulcer, requiring EBP. The facility's policies on PPE and hand hygiene were not followed, as confirmed by nursing and dietary staff.
The facility failed to store and prepare food safely, affecting 60 residents. Beverages were not iced during meal service, leading to milk temperatures above the required 41°F. Additionally, staff did not properly reheat food in the microwave, failing to stir or check temperatures as per policy.
A resident with a history of a stage 2 pressure injury did not receive the necessary care to prevent further injury. Despite a care plan intervention for a pressure-reducing cushion while in a chair, the resident's recliner lacked this cushion. Staff confirmed the absence of the cushion since the resident's admission, leading to a facility-acquired pressure injury.
A resident received incorrect dosages of eye drops, leading to an 8% medication error rate at the facility. The errors involved administering Ketotifen Fumarate 0.035% instead of 0.025% and Good Sense Artificial Tears 0.5%-0.6% instead of 0.4%-0.3%. The facility's stock did not match the prescribed strengths, and staff failed to verify or clarify the correct dosages with the provider.
Failure to Timely Document Neurological Assessment Following Stroke Concern
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to document a neurological assessment for a resident who was suspected of having a stroke. The resident, who had a history of stroke, chronic kidney disease, type 2 diabetes, and atrial fibrillation, was reported by a friend to be experiencing stroke symptoms, including slurred speech and facial droop. The RN assessed the resident for neurological symptoms on the evening of the reported concern but did not record the assessment in the medical record at the time it was performed, as required by facility policy. The omission was discovered during a surveyor's review of the resident's medical record, which revealed no documentation of the neurological assessment prior to the resident's subsequent hospital transfer. The RN later confirmed that the assessment had been completed but was not documented until prompted by the Director of Nursing (DON) several days later. The DON verified that the assessment should have been documented at the time of service, in accordance with facility policy.
Inadequate Catheter Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections for two residents, R13 and R14, as observed by surveyors. On multiple occasions, R13's catheter drainage bag was found uncovered and in contact with the floor, which is against the facility's catheter care policy. The policy requires that catheter drainage bags be covered with a privacy bag and not placed on the floor to prevent contamination. Interviews with Certified Nursing Assistants (CNAs) confirmed that the catheter bag should be hung from the bed and covered, indicating a lapse in adherence to the facility's procedures. Similarly, R14's catheter drainage bag was observed touching the floor and visible from the hallway, which was also verified by a CNA. The Assistant Director of Nursing confirmed that catheter bags should not be on the floor due to infection control issues and should be covered with a privacy bag as per the facility's policy. Both residents had medical conditions requiring catheter use, with R13 having obstructive uropathy and moderately impaired cognition, and R14 having a neurogenic bladder and severely impaired cognition. These observations highlight a deficiency in the facility's catheter care practices, potentially increasing the risk of urinary tract infections.
Failure to Follow Prescribed Diet for Resident
Penalty
Summary
The facility failed to adhere to a prescribed individualized diet for a resident, identified as R11, during a lunch meal on November 26, 2024. The resident was on a consistent carbohydrate (CCHO) diet order, which was not followed as per the meal ticket. Instead of receiving the specified portions and items, R11 was served a full piece of peanut butter pie, a dinner roll, and two glasses of chocolate milk, which deviated from the prescribed diet that included a smaller dessert portion and specific beverages. The deficiency was identified through observation, staff interviews, and record reviews. A Dietary Aide, DA-L, who served the meal, was not familiar with CCHO diets and had not received adequate training on them. The Culinary Director, CD-M, and Registered Dietitian, RD-N, confirmed that the meal served did not comply with the resident's dietary requirements and that staff should follow individualized meal tickets. The Assistant Director of Nursing, ADON-C, indicated that they would consult with Dietary Management regarding the issue.
Infection Control Lapses in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two separate incidents involving staff non-compliance with established protocols. In the first incident, a resident with Alzheimer's disease, dementia, type 2 diabetes mellitus, and a pressure ulcer on the right heel was on Enhanced Barrier Precautions (EBP) due to the pressure injury. Despite this, two Certified Nursing Assistants (CNAs) transferred the resident from a wheelchair to a bed without wearing the required personal protective equipment (PPE). The facility's policy mandates the use of gowns and gloves during high-contact care activities for residents on EBP, which was not adhered to in this case. The Assisted Director of Nursing confirmed that PPE should have been worn during such activities. In the second incident, a Dietary Aide (DA) was observed lifting a garbage can lid with gloved hands and then proceeding to package food without removing the gloves or performing hand hygiene. The DA continued to touch additional items in the kitchen with the same gloves, contrary to the facility's hand hygiene policy, which requires hand washing after handling potentially contaminating items. The Culinary Director and Registered Dietician confirmed that the DA should have followed the facility's hand hygiene and glove use policy, which includes changing gloves and performing hand hygiene as necessary.
Deficiency in Food Storage and Preparation
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a safe and sanitary manner, potentially affecting 60 of the 105 residents. During meal service on two consecutive days, beverages were not kept on ice, resulting in milk temperatures reaching 59 degrees Fahrenheit, which is above the required 41 degrees Fahrenheit as per the Wisconsin State Food Code and the facility's policy. The surveyor observed that beverages were placed on a cart in the dining room without ice until the end of meal service, and only then were they returned to the refrigerator. Additionally, the facility did not adhere to proper procedures for reheating food in a microwave. A staff member heated pre-packaged soup and leftovers without stirring or checking the temperature before serving them to residents. The facility's policy requires that reheated foods reach at least 165 degrees Fahrenheit and be stirred to ensure even heating. The staff member admitted to not knowing the exact temperature of the reheated items and did not follow the facility's policy for reheating food.
Failure to Provide Pressure Ulcer Prevention
Penalty
Summary
The facility failed to provide necessary care and services to prevent a pressure injury from developing and promote healing for a resident identified as R161. R161 had a history of a stage 2 pressure injury on the sacral/coccyx area and was on Hospice care with diagnoses including adult failure to thrive, pressure injury to the sacral region stage 2, and protein calorie malnutrition. The resident's care plan included an intervention for a pressure-reducing cushion while up in a chair. However, during an observation, it was noted that R161 did not have a cushion in their recliner, which was a deviation from the care plan. The facility's Pressure Injury Risk Assessment Policy requires that residents at risk for developing pressure injuries have interventions documented in their care plan. Despite this, R161's recliner did not contain a pressure-reducing cushion, and staff interviews confirmed that R161 had not had such a cushion since admission. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) verified the absence of the cushion and acknowledged the oversight. This lack of adherence to the care plan contributed to the re-opening of R161's pressure injury, which was noted to be facility-acquired.
Medication Error Rate Exceeds 5% Due to Incorrect Eye Drop Dosages
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate during medication administration observations. This deficiency affected one resident, who was administered incorrect doses of two eye drop medications. The resident, who had intact cognition and was responsible for their healthcare decisions, was observed receiving Ketotifen Fumarate 0.035% instead of the prescribed 0.025% and Good Sense Artificial Tears 0.5%-0.6% instead of the prescribed 0.4%-0.3%. These errors were identified during a surveyor's review of the resident's medical record and confirmed through staff interviews. The errors occurred because the facility's stock of eye drops did not match the prescribed strengths, and staff administered the available stock without verifying or clarifying the correct dosage with the resident's provider. The Director of Nursing confirmed that these were medication errors and stated that staff should not administer medications if the available stock does not match the prescribed strength. The facility's Medication Administration policy requires adherence to the six rights of medication administration, which were not followed in this instance.
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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) |
|---|---|---|---|---|
| River's Bend Health Services | 1.9 mi | — | 13 | 0 |
| Shady Lane Nursing Care Center | 3.2 mi | — | 0 | 0 |
| St Marys Home For The Aged | 3.3 mi | — | 10 | 0 |
| North Ridge Health And Rehabilitation Center | 5 mi | — | 20 | 0 |
| Hamilton Health Services | 10.8 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.