Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Maryhill Manor
Niagara, WI · 50 certified beds · Last Life Safety survey March 25, 2026
CMS Certification Number 525467 · first certified June 1990
Ownership
Independently operated (no chain recorded by CMS) · Non profit - Church related
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within WI
13 citations — more than 28% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 2 citations; the earlier surveys in the window averaged 5.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens May 2027 — about 7 months from now. This facility’s last Life Safety survey was March 2026. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Emergency preparedness
1 of the 13 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 13 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 13 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 27, 2023 | 3 |
| November 6, 2024 | 8 |
| March 25, 2026 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 2 | 2026-03-25 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2024-11-06 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2024-11-06 |
| E-0020 | Establish policies and procedures including evacuation. | 1 | 2024-11-06 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 1 | 2023-09-27 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 1 | 2024-11-06 |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | 1 | 2026-03-25 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2024-11-06 |
What the citations cover
- Miscellaneous Deficiencies 4
- Smoke Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Services Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Miscellaneous Deficiencies | 4 |
| Smoke Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Services Deficiencies | 1 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
March 25, 2026 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (April 8, 2026) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (April 8, 2026) |
November 6, 2024 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (December 18, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0751 | Have restrictions on the use of flammable curtains. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Waiver has been granted (March 25, 2025) |
September 27, 2023 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (October 11, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (October 11, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (October 11, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.