4 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
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
1555 Dousman St, Green Bay, WI
(920) 494-4525
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
64
Certified beds
Average residents
51
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1992-04-01
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
Staffing
RN hours / resident day
0.70
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.81
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.27
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.66
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.74
CMS adjusted RN staffing hours
Adjusted total hours
4.55
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
1,755
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.18
Composite VBP score used to determine payment impact.
Payment multiplier
1.0090
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
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
5.89
Baseline 8.45% · Performance 6.24% · Measure score 5.89 · Achievement 5.33 · Improvement 5.89
Total nurse turnover
5.88
Baseline 33.96% · Performance 39.66% · Measure score 5.88 · Achievement 5.88 · Improvement 0
Adjusted total nurse staffing
4.48
Baseline 4.03 hours · Performance 4.35 hours · Measure score 4.48 · Achievement 4.48 · Improvement 1.34
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.65% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 40 · Observed rate 10% · Lower 95% interval 7.07% |
| Discharge to community | 65.73% |
50.57%
15.2 pts better
|
Better than the National Rate · Eligible stays 33 · Observed rate 69.7% · Lower 95% interval 52.85% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 30 · Denominator 30 |
| Falls with major injury | 3.33% |
0.77%
2.6 pts worse
|
Numerator 1 · Denominator 30 |
| Discharge self-care score | 38.46% |
53.69%
15.2 pts worse
|
Numerator 10 · Denominator 26 |
| Discharge mobility score | 46.15% |
50.94%
4.8 pts worse
|
Numerator 12 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 6.67% |
2.29%
4.4 pts worse
|
Numerator 2 · Denominator 30 · Adjusted rate 6.93% |
| Healthcare-associated infections requiring hospitalization | 6.24% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 26 · Observed rate 0% · Lower 95% interval 3.36% |
| Staff COVID-19 vaccination coverage | 12.22% |
8.2%
4 pts better
|
Numerator 11 · Denominator 90 |
| Staff flu vaccination coverage | 71.92% |
42%
29.9 pts better
|
Numerator 146 · Denominator 203 |
| Discharge function score | 38.46% |
56.45%
18 pts worse
|
Numerator 10 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
| 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 | 12.4% |
3.2%
9.2 pts worse
|
3.3%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 15.9% · Q3 13.6% · Q4 10.9% · 4Q avg 12.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.0% |
5.0%
6 pts worse
|
11.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 7.1% · Q3 15.8% · Q4 16.7% · 4Q avg 11.0% |
| Percentage of long-stay residents who lose too much weight | 0.8% |
4.9%
4.1 pts better
|
5.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.1% · Q4 0.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.6% |
16.6%
2 pts better
|
19.6%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 16.1% · Q3 12.1% · Q4 11.4% · 4Q avg 14.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.5% |
16.7%
10.2 pts better
|
16.7%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 3.4% · Q3 6.9% · Q4 5.7% · 4Q avg 6.5% · 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 | 17.5% |
21.1%
3.6 pts better
|
16.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.1% |
17.3%
2.2 pts better
|
14.9%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 25.0% · Q3 6.7% · Q4 12.5% · 4Q avg 15.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.2% |
2.3%
0.9 pts worse
|
1.0%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 6.2% · Q3 2.4% · Q4 1.7% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.2% |
3.0%
1.2 pts worse
|
1.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 7.9% · Q3 2.3% · Q4 2.2% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.1% |
25.5%
16.4 pts better
|
19.8%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 10.6% · Q3 0.0% · Q4 11.2% · 4Q avg 9.1% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
5.5%
1.4 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.0% · Q3 9.4% · Q4 3.1% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
86.8%
10.5 pts better
|
81.7%
15.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 98.1% · Q3 96.6% · Q4 98.4% · 4Q avg 97.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.9% |
15.0%
10.1 pts better
|
12.0%
7.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.9% · Observed 4.3% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.3%
0.1 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.3% · Q4 2.6% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.2% |
82.2%
14 pts better
|
79.7%
16.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.0% |
22.7%
0.3 pts worse
|
23.9%
0.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.0% · Observed 17.4% · Expected 18.0% · Used in QM five-star |
Survey summary
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Resident Rights (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2026-01-16
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2026-01-29
Fire Safety
Use approved construction type or materials.
Corrected 2024-10-25
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-27
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-10
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-23
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-28
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-09-05
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-09-06
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-09-27
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-09-05
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-24
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-07
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-01-30
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-30
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2026-01-30
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2026-01-30
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-11-28
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-27
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-09-11
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-09-11
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-24
Penalties and ownership
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
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