Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
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 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.
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.
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 | — | 0 | 0 |
| River's Bend Health Services | 1.7 mi | — | 13 | 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.