Cycle 1
Health 2025-04-16 · Fire 2025-04-16
3 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Manitowoc, WI
Shady Lane Nursing Care Center
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1235 S 24th St, Manitowoc, WI
(920) 682-8254
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
43
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.14
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.89
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.84
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.95
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.39
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
1.14
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
1.18
CMS adjusted RN staffing hours
Adjusted total hours
5.02
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,300
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.50
Composite VBP score used to determine payment impact.
Payment multiplier
0.9934
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.22
Baseline 18.06% · Performance 20.87% · Measure score 1.22 · Achievement 1.22 · Improvement 0
Healthcare-associated infections
3.45
Baseline 6.68% · Performance 6.80% · Measure score 3.45 · Achievement 3.45 · Improvement 0
Total nurse turnover
6.52
Baseline 40.68% · Performance 37.04% · Measure score 6.52 · Achievement 6.52 · Improvement 1.8
Adjusted total nurse staffing
5.01
Baseline 3.93 hours · Performance 4.50 hours · Measure score 5.01 · Achievement 5.01 · Improvement 2.60
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.88% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 77 · Observed rate 10.39% · Lower 95% interval 7.4% |
| Discharge to community | 60.43% |
50.57%
9.9 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 56.25% · Lower 95% interval 49.54% |
| Medicare spending per beneficiary | 0.71 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 95.65% |
95.27%
0.4 pts better
|
Numerator 44 · Denominator 46 |
| Falls with major injury | 2.17% |
0.77%
1.4 pts worse
|
Numerator 1 · Denominator 46 |
| Discharge self-care score | 19.44% |
53.69%
34.2 pts worse
|
Numerator 7 · Denominator 36 |
| Discharge mobility score | 25% |
50.94%
25.9 pts worse
|
Numerator 9 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 45 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.8% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 42 · Observed rate 4.76% · Lower 95% interval 3.73% |
| Staff COVID-19 vaccination coverage | 5.38% |
8.2%
2.8 pts worse
|
Numerator 10 · Denominator 186 |
| Staff flu vaccination coverage | 76.38% |
42%
34.4 pts better
|
Numerator 194 · Denominator 254 |
| Discharge function score | 30.56% |
56.45%
25.9 pts worse
|
Numerator 11 · Denominator 36 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 27 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 37.04% |
25.2%
11.8 pts better
|
Numerator 10 · Denominator 27 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
3.2%
1.7 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.6% |
5.0%
3.4 pts better
|
11.4%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.2% · Q4 3.4% · 4Q avg 1.6% |
| Percentage of long-stay residents who lose too much weight | 0.9% |
4.9%
4 pts better
|
5.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.3% |
16.6%
7.7 pts worse
|
19.6%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 25.0% · Q3 25.9% · Q4 26.9% · 4Q avg 24.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.5% |
16.7%
5.2 pts better
|
16.7%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 4.8% · Q3 12.5% · Q4 13.0% · 4Q avg 11.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 61.9% |
21.1%
40.8 pts worse
|
16.3%
45.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 61.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.4% |
17.3%
14.1 pts worse
|
14.9%
16.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.1% · Q2 28.0% · Q3 44.0% · Q4 20.8% · 4Q avg 31.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
2.3%
0.6 pts better
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 3.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.4% |
3.0%
2.4 pts worse
|
1.7%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.9% · Q3 3.4% · Q4 6.7% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 38.0% |
25.5%
12.5 pts worse
|
19.8%
18.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.2% · Q2 41.2% · Q3 37.3% · Q4 35.3% · 4Q avg 38.0% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
5.5%
0.3 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 10.2% · Q3 7.8% · Q4 0.0% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
86.8%
12.4 pts better
|
81.7%
17.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.9% · Q3 99.0% · Q4 99.0% · 4Q avg 99.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.4% |
15.0%
1.4 pts worse
|
12.0%
4.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.4% · Observed 14.6% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.8% |
82.2%
14.6 pts better
|
79.7%
17.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.4% |
22.7%
7.3 pts better
|
23.9%
8.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.4% · Observed 12.2% · Expected 18.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-28 · Fire 2024-02-28
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-02-08 · Fire 2023-02-08
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-16
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-04-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-17
F · Potential for more than minimal harm
2025-04-16
K700 · Miscellaneous Deficiencies
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2025-05-08
F · Potential for more than minimal harm
2025-04-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-17
E · Potential for more than minimal harm
2025-04-16
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2025-04-17
E · Potential for more than minimal harm
2025-04-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-17
E · Potential for more than minimal harm
2025-04-16
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-04-17
E · Potential for more than minimal harm
2024-02-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-02-28
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-03-27
D · Potential for more than minimal harm
2023-02-08
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-02-20
Inspection history
Recent health citations
G · Actual harm
2025-04-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-16
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-05-15
D · Potential for more than minimal harm
2023-11-30
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-12-28
Penalties and ownership
What sits behind the stars
Ownership
Avci, Kay
Corporate Director · Individual
Garcia, Heather
Corporate Director · Individual
Goetz, Dayna
Corporate Director · Individual
Herzog, Chris
Corporate Director · Individual
Less, David
Corporate Director · Individual
Meerdink, Todd
Operational/Managerial Control · Individual
Meerdink, Todd
Corporate Officer · Individual
Neilson, Jody
Corporate Director · Individual
Neu, Matthew
Corporate Director · Individual
Nichter, Monica
Corporate Director · Individual
Sconzert, Aaron
Operational/Managerial Control · Individual
Sconzert, Aaron
Corporate Officer · Individual
Tienor, Dennis
Corporate Director · Individual
Verlinden, Laurence
Operational/Managerial Control · Individual
Verlinden, Laurence
Corporate Director · Individual
Weigel, Amy
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
St Marys Home for the Aged
Manitowoc, WI
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
River's Bend Health Services
Manitowoc, WI
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
North Ridge Health and Rehabilitation Center
Manitowoc, WI
2-star overall rating with 2-star inspections with 13 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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