11 health deficiencies
Top issue: Infection Control (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
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
1229 S Jackson St, Green Bay, WI
(920) 437-6523
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
88
Certified beds
Average residents
60
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-01-01
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
1.01
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.61
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.62
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.24
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.62
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.71
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.64
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.00
CMS adjusted RN staffing hours
Adjusted total hours
4.20
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Program rank
5,973
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.4
Composite VBP score used to determine payment impact.
Payment multiplier
0.9884
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.10
Baseline 18.07% · Performance 20.46% · Measure score 2.10 · Achievement 2.10 · Improvement 0
Healthcare-associated infections
4.33
Baseline 6.17% · Performance 6.54% · Measure score 4.33 · Achievement 4.33 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
3.88
Baseline 4.64 hours · Performance 4.18 hours · Measure score 3.88 · Achievement 3.88 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.3% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 145 · Observed rate 10.34% · Lower 95% interval 7.65% |
| Discharge to community | 63.56% |
50.57%
13 pts better
|
Better than the National Rate · Eligible stays 143 · Observed rate 58.74% · Lower 95% interval 56.55% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 95.59% |
95.27%
0.3 pts better
|
Numerator 65 · Denominator 68 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 68 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 28 · Denominator 56 |
| Discharge mobility score | 44.64% |
50.94%
6.3 pts worse
|
Numerator 25 · Denominator 56 |
| Pressure ulcers or injuries, new or worsened | 4.41% |
2.29%
2.1 pts worse
|
Numerator 3 · Denominator 68 · Adjusted rate 4.16% |
| Healthcare-associated infections requiring hospitalization | 6.54% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 82 · Observed rate 4.88% · Lower 95% interval 3.56% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 101 |
| Staff flu vaccination coverage | 12.64% |
42%
29.4 pts worse
|
Numerator 23 · Denominator 182 |
| Discharge function score | 62.5% |
56.45%
6 pts better
|
Numerator 35 · Denominator 56 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 36 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 50% |
25.2%
24.8 pts better
|
Numerator 18 · Denominator 36 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
95.7%
3.7 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.8% · Q4 100.0% · 4Q avg 99.4% |
| 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 | 2.2% |
3.2%
1 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.2% · Q3 2.2% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.1% |
5.0%
1.1 pts worse
|
11.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 6.8% · Q3 9.1% · Q4 2.7% · 4Q avg 6.1% |
| Percentage of long-stay residents who lose too much weight | 6.5% |
4.9%
1.6 pts worse
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 4.8% · Q3 0.0% · Q4 5.6% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.6% |
16.6%
2 pts worse
|
19.6%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 16.7% · Q3 20.0% · Q4 16.7% · 4Q avg 18.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.1% |
16.7%
6.6 pts better
|
16.7%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 8.6% · Q3 9.4% · Q4 10.3% · 4Q avg 10.1% · 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 | 20.7% |
21.1%
0.4 pts better
|
16.3%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.8% |
17.3%
1.5 pts worse
|
14.9%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 13.2% · Q3 18.9% · Q4 23.5% · 4Q avg 18.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.0% |
2.3%
2.7 pts worse
|
1.0%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 1.5% · Q3 5.6% · Q4 7.9% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
3.0%
0.4 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 4.3% · Q4 7.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.2% |
25.5%
6.7 pts worse
|
19.8%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.7% · Q2 26.3% · Q3 34.2% · Q4 40.7% · 4Q avg 32.2% |
| Percentage of long-stay residents with pressure ulcers | 1.6% |
5.5%
3.9 pts better
|
5.1%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.4% · Q3 1.7% · Q4 1.6% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.4% |
86.8%
8.6 pts better
|
81.7%
13.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.6% · Q2 93.5% · Q3 96.8% · Q4 98.4% · 4Q avg 95.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.6% |
15.0%
1.6 pts worse
|
12.0%
4.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 15.0% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
1.3%
1 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.8% · Q3 1.5% · Q4 1.9% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.6% |
82.2%
5.4 pts better
|
79.7%
7.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.0% |
22.7%
7.7 pts better
|
23.9%
8.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.0% · Observed 15.0% · Expected 23.8% · Used in QM five-star |
Survey summary
Top issue: Infection Control (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Nutrition and Dietary (4 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Infection Control (5 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-07-09
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-07-09
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-07
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-07
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-06-07
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 2025-05-28
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 2025-06-07
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-06-07
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-04-12
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-04-12
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-04-12
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-12
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-04-12
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-04-12
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-12
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-12
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 2024-04-12
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-12
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-04-12
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-04-12
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 2024-04-12
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-12
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-14
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-03
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-04-03
Inspection history
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-12-15
Health
Respond appropriately to all alleged violations.
Corrected 2025-12-15
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-12-15
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-16
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2025-06-07
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-06-07
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-07
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-06-07
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-06-07
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-06-07
Health
Implement a program that monitors antibiotic use.
Corrected 2025-06-07
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-02-09
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-09
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-02-09
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-02-09
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-09
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-07
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-12
Health
Dispose of garbage and refuse properly.
Corrected 2024-04-12
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-04-12
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-12
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-04-12
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 2024-04-12
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2024-04-12
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-04-12
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-04-12
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-12
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-04-12
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 2024-04-12
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-12
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-12
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-04-12
Health
Post nurse staffing information every day.
Corrected 2024-04-12
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-10-02
Health
Respond appropriately to all alleged violations.
Corrected 2023-10-02
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-07-24
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-07-24
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-19
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-19
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-03
Health
Implement a program that monitors antibiotic use.
Corrected 2023-04-03
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-04-03
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-04-03
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-03
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-04-03
Penalties and ownership
Fine · fine $4,938
Fine
Fine · fine $4,938
Fine
Fine · fine $14,814
Fine
Fine · fine $4,938
Fine
Fine · fine $4,587
Fine
Fine · fine $13,762
Fine
Fine · fine $4,587
Fine
Fine · fine $4,587
Fine
Fine · fine $4,587
Fine
Fine · fine $4,587
Fine
Fine · fine $4,545
Fine
Fine · fine $4,235
Fine
Fine · fine $3,882
Fine
Fine · fine $3,529
Fine
Fine · fine $3,176
Fine
Fine · fine $2,797
Fine
Fine · fine $2,447
Fine
Fine · fine $2,098
Fine
Fine · fine $4,194
Fine
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
W-2 Managing Employee · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Nearby options
Green Bay, WI
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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
Green Bay, WI
2-star overall rating with 3-star inspections with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Jump out