Maryhill Manor
Niagara, Marinette County, Wisconsin · CCN 525467 · Non-profit (Church related) · not part of a chain
CMS rates Maryhill Manor 4 of 5 overall as of August 2026. 50 certified beds, 48 residents a day on average. 18 citations on record from the current inspection cycles, 1 at immediate jeopardy; 1 fine totalling $50,606.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★★★☆ 4 of 5 |
|---|---|
| Health inspections | ★★★☆☆ 3 of 5 |
| Staffing | ★★★★☆ 4 of 5 |
| Quality measures | ★★★★★ 5 of 5 |
| Quality: long-stay / short-stay | 5 / — of 5 |
Staffing
| Total nurse staffing | 3.85694 hours per resident per day |
|---|---|
| Registered nurses | 0.96016 hours per resident per day |
| Weekend total | 3.58348 hours per resident per day |
| Nursing staff turnover | 45.3% (registered nurses 50%) |
| Administrators who left | 0 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-06-16 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-07-07 |
| 2026-03-25 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2026-04-08 |
| 2026-03-25 | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Resident Assessment and Care Planning Deficiencies · tag F0640 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-08 |
| 2026-03-25 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-08 |
| 2026-02-04 complaint survey |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-02-26 |
| 2026-02-04 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-02-26 |
| 2025-03-10 complaint survey |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-24 |
| 2025-03-10 complaint survey |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · tag F0657 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-24 |
| 2024-12-18 complaint survey |
Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · tag F0583 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-01-07 |
| 2024-11-06 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-11-18 |
| 2024-11-06 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · tag F0883 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-18 |
| 2024-06-25 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2024-07-10 |
| 2024-06-25 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-10 |
| 2024-06-25 complaint survey |
Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-10 |
| 2023-09-27 | 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. Nutrition and Dietary Deficiencies · tag F0803 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2023-10-20 |
| 2023-09-27 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2023-10-20 |
| 2023-09-27 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-20 |
| 2023-09-27 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-11 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2024-06-25 | Fine | $50,606 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| First Bank Upper Michigan Organization | 5% or greater mortgage interest | — | 2022-11-30 |
| Healthdirect Institutional Pharmacy Services Inc. Organization | adp of the snf | — | 2025-12-02 |
| Prime Time Healthcare LLC Organization | adp of the snf | — | 2025-12-02 |
| Up Rehab Services LLC Organization | adp of the snf | — | 2025-12-02 |
| Wipfli LLP Organization | adp of the snf | — | 2025-12-02 |
| Healthdirect Institutional Pharmacy Services Inc. Organization | operational/managerial control | — | 2018-06-01 |
| Prime Time Healthcare LLC Organization | operational/managerial control | — | 2019-11-01 |
| Up Rehab Services LLC Organization | operational/managerial control | — | 2018-06-01 |
| Wipfli LLP Organization | operational/managerial control | — | 1999-01-01 |
| Baier, Patricia Individual | adp of the snf | — | 2016-01-01 |
| Brasure, Ann Individual | adp of the snf | — | 2024-01-01 |
| Crockford, Lynne Individual | adp of the snf | — | 2020-01-01 |
| Decker, Dan Individual | adp of the snf | — | 2024-01-01 |
| Ebli, Jim Individual | adp of the snf | — | 2024-01-01 |
| Frantz, Lana Individual | adp of the snf | — | 2016-01-01 |
| Fredrick, Audrey Individual | adp of the snf | — | 2024-01-01 |
| Hayes, Paul Individual | adp of the snf | — | 2021-01-01 |
| Herriges, Rosemary Individual | adp of the snf | — | 2021-01-01 |
| Kaldor, Carrie Individual | adp of the snf | — | 1999-01-01 |
| Mattson, Ann Individual | adp of the snf | — | 2024-01-01 |
| Pultz, Robert Individual | adp of the snf | — | 2016-01-01 |
| Sikora, Christy Individual | adp of the snf | — | 2021-05-18 |
| Baier, Patricia Individual | corporate director | — | 2016-01-01 |
| Frantz, Lana Individual | corporate director | — | 2016-01-01 |
| Fredrick, Audrey Individual | corporate director | — | 2024-01-01 |
| Herriges, Rosemary Individual | corporate director | — | 2016-01-01 |
| Mattson, Ann Individual | corporate director | — | 2024-01-01 |
| Pultz, Robert Individual | corporate director | — | 2016-01-01 |
| Brasure, Ann Individual | corporate officer | — | 2024-01-01 |
| Crockford, Lynne Individual | corporate officer | — | 2020-01-01 |
| Decker, Dan Individual | corporate officer | — | 2024-01-01 |
| Ebli, Jim Individual | corporate officer | — | 2024-01-01 |
| Baier, Patricia Individual | operational/managerial control | — | 2016-01-01 |
| Brasure, Ann Individual | operational/managerial control | — | 2024-01-01 |
| Crockford, Lynne Individual | operational/managerial control | — | 2020-01-01 |
| Decker, Dan Individual | operational/managerial control | — | 2024-01-01 |
| Ebli, Jim Individual | operational/managerial control | — | 2024-01-01 |
| Frantz, Lana Individual | operational/managerial control | — | 2016-01-01 |
| Fredrick, Audrey Individual | operational/managerial control | — | 2024-01-01 |
| Hayes, Paul Individual | operational/managerial control | — | 2021-01-01 |
| Herriges, Rosemary Individual | operational/managerial control | — | 2021-01-01 |
| Kaldor, Carrie Individual | operational/managerial control | — | 1999-01-01 |
| Mattson, Ann Individual | operational/managerial control | — | 2024-01-01 |
| Pultz, Robert Individual | operational/managerial control | — | 2016-01-01 |
| Sikora, Christy Individual | operational/managerial control | — | 2021-05-18 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Maryhill Manor.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Marinette County.