Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Shady Lane Nursing Care Center during CMS and state inspections, most recent first.
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.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 111 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | — | 13 | 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 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Shady Lane Nursing Care Center.
100% money-back within 48 hours.
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.