Cycle 1
Health 2025-12-03 · Fire 2025-12-03
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Manitowoc, WI
St Marys Home for the Aged
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1635 S 21st Street, Manitowoc, WI
(920) 684-7171
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
84
Certified beds
Average residents
48
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Felician Services
Operator or chain grouping
Approved since
1996-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
3 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 quality stars
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
1.03
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.31
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.99
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.34
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.88
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.75
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.02
CMS adjusted RN staffing hours
Adjusted total hours
4.27
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
41%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,783
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.76
Composite VBP score used to determine payment impact.
Payment multiplier
1.0014
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.58
Baseline 18.04% · Performance 20.24% · Measure score 2.58 · Achievement 2.58 · Improvement 0
Healthcare-associated infections
7.82
Baseline 6.31% · Performance 5.50% · Measure score 7.82 · Achievement 7.82 · Improvement 5.69
Total nurse turnover
2.17
Performance 54.80% · Measure score 2.17 · Achievement 2.17 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
6.53
Baseline 3.86 hours · Performance 4.94 hours · Measure score 6.53 · Achievement 6.53 · Improvement 5.11
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.82% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 132 · Observed rate 9.85% · Lower 95% interval 7.5% |
| Discharge to community | 60.11% |
50.57%
9.5 pts better
|
Better than the National Rate · Eligible stays 125 · Observed rate 58.4% · Lower 95% interval 53.89% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 88.61% |
95.27%
6.7 pts worse
|
Numerator 70 · Denominator 79 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 79 |
| Discharge self-care score | 37.88% |
53.69%
15.8 pts worse
|
Numerator 25 · Denominator 66 |
| Discharge mobility score | 45.45% |
50.94%
5.5 pts worse
|
Numerator 30 · Denominator 66 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 79 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.5% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 77 · Observed rate 1.3% · Lower 95% interval 3.07% |
| Staff COVID-19 vaccination coverage | 5.37% |
8.2%
2.8 pts worse
|
Numerator 8 · Denominator 149 |
| Staff flu vaccination coverage | 51.56% |
42%
9.6 pts better
|
Numerator 99 · Denominator 192 |
| Discharge function score | 42.42% |
56.45%
14 pts worse
|
Numerator 28 · Denominator 66 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 30 · Denominator 30 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 33 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 48.94% |
25.2%
23.7 pts better
|
Numerator 23 · Denominator 47 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.3 |
1.6
1.3 pts better
|
1.9
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.2 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
2.2
1.1 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.8 · Expected 1.2 · Used in QM five-star |
| 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 | 94.6% |
95.0%
0.4 pts worse
|
95.5%
0.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.2%
0.1 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 5.7% · Q3 3.3% · Q4 0.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.0%
5 pts better
|
11.4%
11.4 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 who lose too much weight | 1.2% |
4.9%
3.7 pts better
|
5.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q4 0.0% · 4Q avg 1.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.3% |
16.6%
2.7 pts worse
|
19.6%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 20.0% · Q4 9.1% · 4Q avg 19.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.8% |
16.7%
4.9 pts better
|
16.7%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.8% · 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 | 27.8% |
21.1%
6.7 pts worse
|
16.3%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.1% |
17.3%
6.8 pts worse
|
14.9%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q4 28.6% · 4Q avg 24.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
2.3%
0.4 pts better
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 0.0% · Q4 5.2% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 10.8% |
3.0%
7.8 pts worse
|
1.7%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 17.1% · Q3 6.7% · Q4 6.2% · 4Q avg 10.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.1% |
25.5%
4.6 pts worse
|
19.8%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 47.7% · Q3 36.3% · Q4 10.7% · 4Q avg 30.1% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
5.5%
3.5 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 2.4% · Q4 2.2% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
86.8%
10.4 pts better
|
81.7%
15.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.7% · Q2 98.9% · Q3 97.9% · Q4 97.1% · 4Q avg 97.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.6% |
15.0%
2.6 pts worse
|
12.0%
5.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.6% · Observed 16.5% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.3%
0.6 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 3.4% · Q4 1.6% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.1% |
82.2%
8.9 pts better
|
79.7%
11.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.6% |
22.7%
9.9 pts worse
|
23.9%
8.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.6% · Observed 25.3% · Expected 18.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-14 · Fire 2024-08-14
1 health deficiencies
Top issue: Infection Control (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-06-22 · Fire 2023-06-22
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-03
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2026-01-03
F · Potential for more than minimal harm
2025-12-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-02-06
E · Potential for more than minimal harm
2025-12-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-03
E · Potential for more than minimal harm
2025-12-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2026-01-03
F · Potential for more than minimal harm
2024-08-14
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-09-11
F · Potential for more than minimal harm
2024-08-14
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-09-03
F · Potential for more than minimal harm
2024-08-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-17
F · Potential for more than minimal harm
2024-08-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-14
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-09-11
E · Potential for more than minimal harm
2024-08-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-11
E · Potential for more than minimal harm
2024-08-14
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-09-11
D · Potential for more than minimal harm
2024-08-14
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 2024-09-11
D · Potential for more than minimal harm
2023-06-22
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-07-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-03
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-01-03
D · Potential for more than minimal harm
2025-12-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-03
D · Potential for more than minimal harm
2025-12-03
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2026-01-03
D · Potential for more than minimal harm
2025-12-03
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 2026-01-03
D · Potential for more than minimal harm
2025-12-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2026-01-03
D · Potential for more than minimal harm
2025-12-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-03
D · Potential for more than minimal harm
2025-04-30
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-05-30
D · Potential for more than minimal harm
2024-08-14
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-09-14
F · Potential for more than minimal harm
2023-06-22
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-22
D · Potential for more than minimal harm
2023-06-22
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-22
D · Potential for more than minimal harm
2023-06-22
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-07-22
D · Potential for more than minimal harm
2023-06-22
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-07-22
Penalties and ownership
What sits behind the stars
Ownership
Felician Services Inc
5% Or Greater Direct Ownership Interest · Organization
Bruckschen, Megan
Corporate Director · Individual
Bruckschen, Megan
W-2 Managing Employee · Individual
Corbeil, Lindsey
Corporate Director · Individual
Corbeil, Lindsey
W-2 Managing Employee · Individual
Denor, Jeremy
Corporate Director · Individual
Denor, Jeremy
W-2 Managing Employee · Individual
Donlon, Marcia
Corporate Director · Individual
Etheridge, Michael
Corporate Director · Individual
Felician Services Inc
5% Or Greater Mortgage Interest · Organization
Goetz, Cameron
Corporate Director · Individual
Hillmer, Michael
Corporate Director · Individual
Hillmer, Michael
W-2 Managing Employee · Individual
Jacobi, Roselle
Corporate Director · Individual
Jacobi, Roselle
W-2 Managing Employee · Individual
Maurer, Mary
Corporate Director · Individual
Miller, Michael
Corporate Director · Individual
Miller, Michael
W-2 Managing Employee · Individual
Otten, Shannon
Corporate Director · Individual
Otten, Shannon
Corporate Officer · Individual
Otten, Shannon
W-2 Managing Employee · Individual
Sauer, Matthew
Corporate Director · Individual
Schubert, Luke
Corporate Director · Individual
Schubert, Luke
W-2 Managing Employee · Individual
Sidhu, Sarfraz
Contracted Managing Employee · Individual
Soltys, Frank
Corporate Director · Individual
Spies, Barbara
Corporate Director · Individual
Spies, Barbara
W-2 Managing Employee · Individual
Swetlik, Dennis
Corporate Director · Individual
Thompson, Renee
Corporate Director · Individual
Thompson, Renee
W-2 Managing Employee · Individual
Veeser, Thomas
Corporate Director · Individual
Wech, Darcy
Corporate Director · Individual
Wech, Darcy
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Shady Lane Nursing Care Center
Manitowoc, WI
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 7 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
Jump out