Maryhill Manor
Open-data reference.
Maryhill Manor is a non profit - church related facility in NIAGARA, WI with 50 certified beds and a 5-star overall CMS rating. The facility has 16 deficiency records on file. Total penalties: $51K.
501 MADISON AVE, NIAGARA, WI 54151
Phone: 7152513172
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 525467
- Ownership
- Non profit - Church related
- Provider Type
- Medicare and Medicaid
- Beds
- 50
- Residents
- 47
- In Hospital
- No
- County
- Marinette
- Last Inspection
- Nov 6, 2024
Staffing Data
- RN Hours
- 1.01 (nat'l avg: 0.68)
- LPN Hours
- 0.25
- CNA Hours
- 2.89
- Total Nursing Hours
- 4.14 (nat'l avg: 3.89)
- PT Hours
- 0.01
- Nursing Turnover
- 40.6%
- RN Turnover
- 26.7%
What the CMS Record Reveals About Maryhill Manor
Maryhill Manor operates 50 certified beds in NIAGARA, WI with approximately 47 residents currently in care, and carries a CMS overall rating of 5 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (3★), staffing levels (5★), and quality measures (5★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 16 deficiency records from recent surveys, of which 1 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $51K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 4.14 total nursing hours per resident day (national average 3.89), with RN coverage at 1.01 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "Non profit - Church related" ownership and operating as a "Medicare and Medicaid" provider, Maryhill Manor falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 40.6%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (16 most recent)
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 24, 2025
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Mar 24, 2025
Keep residents' personal and medical records private and confidential.
Category: Resident Rights Deficiencies
Corrected: Jan 7, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Nov 18, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Nov 18, 2024
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jul 10, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jul 10, 2024
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jul 10, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Oct 11, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Oct 20, 2023
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Category: Nutrition and Dietary Deficiencies
Corrected: Oct 20, 2023
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Oct 20, 2023
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 1, 2022
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 23, 2022
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category: Resident Rights Deficiencies
Corrected: Sep 30, 2022
Give the resident's representative the ability to exercise the resident's rights.
Category: Resident Rights Deficiencies
Corrected: Oct 14, 2022
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 13.5% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 5.5% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 6.6% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 2.6% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 3.4% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 100.0% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.0% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 16.8% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 8.7% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | N/A | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 1.2% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 18.4% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 7.1% | Yes |
Penalty History 1 penalties totaling $51K
| Date | Type | Amount |
|---|---|---|
| Jun 25, 2024 | Fine | $51K |
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Frequently Asked Questions
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Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.