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
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.76
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.17
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.85
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
1.93
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.37
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
1.37
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
1.95
CMS adjusted RN staffing hours
Adjusted total hours
5.32
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
98
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
85.92
Composite VBP score used to determine payment impact.
Payment multiplier
1.0268
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
9.02
Baseline 27.27% · Performance 26.83% · Measure score 9.02 · Achievement 9.02 · Improvement 1.33
Adjusted total nurse staffing
8.17
Baseline 5.39 hours · Performance 5.40 hours · Measure score 8.17 · Achievement 8.17 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 13 · 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 9 · 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 7 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 7 · 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 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 3.13% |
8.2%
5.1 pts worse
|
Numerator 3 · Denominator 96 |
| Staff flu vaccination coverage | 97.06% |
42%
55.1 pts better
|
Numerator 99 · Denominator 102 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
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 · 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 | 3.4% |
3.2%
0.2 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 3.4% · Q4 6.5% · 4Q avg 3.4% · Used in QM five-star |
| 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 · Q1 10.7% · Q2 10.0% · Q3 3.4% · Q4 0.0% · 4Q avg 6.0% |
| 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 · Q2 0.0% · Q3 4.8% · Q4 0.0% · 4Q avg 1.2% |
| 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 · Q2 23.8% · Q3 28.6% · Q4 30.4% · 4Q avg 28.6% |
| 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 · Q3 10.0% · Q4 9.5% · 4Q avg 17.9% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · 4Q avg 11.0% · Used in QM five-star |
| 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 · Q2 15.0% · Q3 4.8% · Q4 13.0% · 4Q avg 9.8% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.3% · 4Q avg 0.9% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 6.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| 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 · Q1 18.6% · Q2 21.6% · Q3 28.0% · Q4 17.8% · 4Q avg 21.5% |
| 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 · Q1 0.0% · Q2 7.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| 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 · 4Q avg 100.0% |
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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