Cycle 1
Health 2025-02-19 · Fire 2025-02-19
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Sturgeon Bay, WI
Door County Memorial Hospital SNF
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
323 S 18th Ave, Sturgeon Bay, WI
(920) 743-5566
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
32
Certified beds
Average residents
31
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1984-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.76
Registered nurse staffing
LPN hours / resident day
0.17
Licensed practical nurse staffing
Aide hours / resident day
2.85
Nurse aide staffing
Weekend hours
4.37
Weekend nurse staffing
RN turnover
27%
Annual RN turnover
Total nurse turnover
49%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.2%
0.2 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 6.0% |
5.0%
1 pts worse
|
11.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.6% |
16.6%
12 pts worse
|
19.6%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 17.9% |
16.7%
1.2 pts worse
|
16.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.0% |
21.1%
10.1 pts better
|
16.3%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.8% |
17.3%
7.5 pts better
|
14.9%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
2.3%
1.4 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
3.0%
1.3 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.5% |
25.5%
4 pts better
|
19.8%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
5.5%
3.6 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
86.8%
13.2 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-04 · Fire 2024-01-04
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-11-09 · Fire 2022-11-09
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-19
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-03-11
F · Potential for more than minimal harm
2025-02-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-06
E · Potential for more than minimal harm
2025-02-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-26
F · Potential for more than minimal harm
2024-01-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-01-31
F · Potential for more than minimal harm
2024-01-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-11
E · Potential for more than minimal harm
2024-01-04
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-06-11
E · Potential for more than minimal harm
2024-01-04
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-01-08
E · Potential for more than minimal harm
2024-01-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-31
E · Potential for more than minimal harm
2024-01-04
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-01-08
D · Potential for more than minimal harm
2024-01-04
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-01-08
D · Potential for more than minimal harm
2024-01-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-04
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-01-08
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-02
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-07-23
D · Potential for more than minimal harm
2025-07-02
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-07-27
D · Potential for more than minimal harm
2025-07-02
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-07-23
E · Potential for more than minimal harm
2025-02-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-02-19
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-02-22
D · Potential for more than minimal harm
2025-02-19
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 2025-03-12
E · Potential for more than minimal harm
2024-01-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-12
Penalties and ownership
What sits behind the stars
Ownership
Alberts, Jamie
Operational/Managerial Control · Individual
Alberts, Jamie
Corporate Director · Individual
Andreae, Bradley
Operational/Managerial Control · Individual
Andreae, Bradley
Corporate Director · Individual
Antonio, Maria Chona
Operational/Managerial Control · Individual
Bohrman, Nancy
Operational/Managerial Control · Individual
Collison, Edgar
Operational/Managerial Control · Individual
Collison, Edgar
Corporate Director · Individual
Conroy, Bernadette
Operational/Managerial Control · Individual
Conroy, Bernadette
Corporate Director · Individual
Dahl, Corwin
Operational/Managerial Control · Individual
Dahl, Corwin
Corporate Director · Individual
Dempster, Dorene
Operational/Managerial Control · Individual
Dempster, Dorene
Corporate Director · Individual
Erickson, Robert
Operational/Managerial Control · Individual
Erickson, Robert
Corporate Director · Individual
Helgeson, Erin
Operational/Managerial Control · Individual
Helgeson, Erin
Corporate Director · Individual
Helm, Pauline
Operational/Managerial Control · Individual
Helm, Pauline
Corporate Director · Individual
Jarosh, Jonathan
Operational/Managerial Control · Individual
Jarosh, Jonathan
Corporate Director · Individual
Kitchens, Joel
Operational/Managerial Control · Individual
Kitchens, Joel
Corporate Director · Individual
Laluzerne, Andrew
Operational/Managerial Control · Individual
Laluzerne, Andrew
Corporate Officer · Individual
Rabas, Jeffrey
Operational/Managerial Control · Individual
Rabas, Jeffrey
Corporate Director · Individual
Richmond, Andrew
Operational/Managerial Control · Individual
Richmond, Andrew
Corporate Director · Individual
St Jean, Michael
Operational/Managerial Control · Individual
St Jean, Michael
Corporate Director · Individual
St Vincent Hospital-Hospital Sisters-Third Order Of St Francis
Operational/Managerial Control · Organization
Stephens, Brian
Operational/Managerial Control · Individual
Stephens, Brian
Corporate Officer · Individual
Sternard, Tammy
Operational/Managerial Control · Individual
Sternard, Tammy
Corporate Director · Individual
Urban, Caroline
Operational/Managerial Control · Individual
Vickman, Patricia
Operational/Managerial Control · Individual
Vickman, Patricia
Corporate Director · Individual
Ziegelbauer, Martha
Operational/Managerial Control · Individual
Ziegelbauer, Martha
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Sturgeon Bay Health Services
Sturgeon Bay, WI
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Amethyst Health Of Algoma
Algoma, WI
2-star overall rating with 2-star inspections with $8,152 in total fines with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Luther Home
Marinette, WI
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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