Cycle 1
Health 2024-12-11 · Fire 2024-12-11
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
14 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Green Bay, WI
Brown Cty Comm Treatment Ctr-Bayshore Village
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
3150 Gershwin Drive, Green Bay, WI
(920) 391-4700
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
63
Certified beds
Average residents
60
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2007-12-29
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
0.70
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.12
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.78
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.66
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.19
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.87
CMS adjusted RN staffing hours
Adjusted total hours
5.91
CMS adjusted total nurse staffing hours
Case-mix index
1.11
Higher values indicate more complex resident acuity
RN turnover
11%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
107
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
85.08
Composite VBP score used to determine payment impact.
Payment multiplier
1.0267
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
7.02
Baseline 38.46% · Performance 35.00% · Measure score 7.02 · Achievement 7.02 · Improvement 2.04
Adjusted total nurse staffing
10
Baseline 5.36 hours · Performance 5.91 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 4 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 15.76% |
8.2%
7.6 pts better
|
Numerator 26 · Denominator 165 |
| Staff flu vaccination coverage | 79.43% |
42%
37.4 pts better
|
Numerator 166 · Denominator 209 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.6
0.3 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 0.9 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
2.2
0.6 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.5 · 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 | 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 | 2.9% |
3.2%
0.3 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.3% · Q3 3.4% · Q4 3.4% · 4Q avg 2.9% · 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 | 3.3% |
4.9%
1.6 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 3.8% · Q3 3.7% · Q4 0.0% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 37.6% |
16.6%
21 pts worse
|
19.6%
18 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 39.3% · Q3 39.3% · Q4 38.2% · 4Q avg 37.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 44.9% |
16.7%
28.2 pts worse
|
16.7%
28.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.4% · Q2 42.4% · Q3 46.9% · Q4 50.0% · 4Q avg 44.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 2.9% |
0.1%
2.8 pts worse
|
0.1%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.3% · Q3 3.4% · Q4 3.4% · 4Q avg 2.9% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.6% |
21.1%
3.5 pts better
|
16.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.0% · Q2 10.6% · Q3 15.9% · Q4 14.3% · 4Q avg 17.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.5% |
17.3%
0.2 pts worse
|
14.9%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 20.4% · Q3 18.9% · Q4 13.5% · 4Q avg 17.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
3.0%
0.8 pts better
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.9% |
25.5%
3.6 pts better
|
19.8%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.6% · Q2 18.7% · Q3 17.8% · Q4 19.8% · 4Q avg 21.9% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
5.5%
3.3 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.5% · Q3 0.0% · Q4 4.3% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.5% |
86.8%
6.7 pts better
|
81.7%
11.8 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 93.5% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-30 · Fire 2023-08-30
6 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-09-08 · Fire 2022-09-08
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-11
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-12-26
F · Potential for more than minimal harm
2024-12-11
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-12-26
F · Potential for more than minimal harm
2024-12-11
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-12-27
F · Potential for more than minimal harm
2024-12-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-26
F · Potential for more than minimal harm
2024-12-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-30
F · Potential for more than minimal harm
2024-12-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-26
F · Potential for more than minimal harm
2024-12-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-31
E · Potential for more than minimal harm
2024-12-11
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2025-04-30
E · Potential for more than minimal harm
2024-12-11
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-12-30
E · Potential for more than minimal harm
2024-12-11
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 2025-01-11
E · Potential for more than minimal harm
2024-12-11
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-12-26
E · Potential for more than minimal harm
2024-12-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-11
E · Potential for more than minimal harm
2024-12-11
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-12-26
D · Potential for more than minimal harm
2024-12-11
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-12-27
F · Potential for more than minimal harm
2023-08-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-30
F · Potential for more than minimal harm
2023-08-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-30
F · Potential for more than minimal harm
2023-08-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-30
F · Potential for more than minimal harm
2023-08-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-30
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-09-30
F · Potential for more than minimal harm
2022-09-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-03
F · Potential for more than minimal harm
2022-09-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-10-03
F · Potential for more than minimal harm
2022-09-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-03
E · Potential for more than minimal harm
2022-09-08
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-10-03
E · Potential for more than minimal harm
2022-09-08
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-10-03
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-12-11
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 2024-12-30
E · Potential for more than minimal harm
2023-08-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-30
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-30
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-30
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-30
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-30
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-09-30
E · Potential for more than minimal harm
2022-09-08
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 2022-10-03
D · Potential for more than minimal harm
2022-09-08
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-10-03
D · Potential for more than minimal harm
2022-09-08
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-10-03
D · Potential for more than minimal harm
2022-09-08
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 2022-10-03
D · Potential for more than minimal harm
2022-09-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-03
D · Potential for more than minimal harm
2022-09-08
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 2022-10-03
Penalties and ownership
What sits behind the stars
Ownership
County Of Brown
5% Or Greater Direct Ownership Interest · Organization
Gruber, Kara
Operational/Managerial Control · Individual
Ramnanan, Keshni
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Edenbrook Of Green Bay
Green Bay, WI
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Odd Fellow Home
Green Bay, WI
2-star overall rating with 2-star inspections with $97,228 in total fines with 11 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Grancare Nursing Center
Green Bay, WI
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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