Sister Bay, WI

Serenity Spring Senior Living At Scandia Village

2-star overall rating with 2-star inspections with 11 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

10560 Applewood Rd, Sister Bay, WI

(920) 854-2317

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Continuum Healthcare

Operator or chain grouping

Approved since

1992-10-11

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.98

Registered nurse staffing

LPN hours / resident day

0.59

Licensed practical nurse staffing

Aide hours / resident day

2.09

Nurse aide staffing

Weekend hours

3.02

Weekend nurse staffing

RN turnover

63%

Annual RN turnover

Total nurse turnover

77%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.6	1.6 1 pts better	1.9 1.3 pts better	Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days	4.1	2.2 1.9 pts worse	1.8 2.3 pts worse	Long Stay · 20240701-20250630
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	96.9%	95.0% 1.9 pts better	95.5% 1.4 pts better	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	4.9%	3.2% 1.7 pts worse	3.3% 1.6 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	1.9%	5.0% 3.1 pts better	11.4% 9.5 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	3.7%	4.9% 1.2 pts better	5.4% 1.7 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	23.9%	16.6% 7.3 pts worse	19.6% 4.3 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	22.7%	16.7% 6 pts worse	16.7% 6 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	23.9%	21.1% 2.8 pts worse	16.3% 7.6 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	24.3%	17.3% 7 pts worse	14.9% 9.4 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.6%	2.3% 0.7 pts better	1.0% 0.6 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	0.8%	3.0% 2.2 pts better	1.7% 0.9 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	27.6%	25.5% 2.1 pts worse	19.8% 7.8 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	8.1%	5.5% 2.6 pts worse	5.1% 3 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	94.3%	86.8% 7.5 pts better	81.7% 12.6 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	15.5%	15.0% 0.5 pts worse	12.0% 3.5 pts worse	Short Stay · 20240701-20250630
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
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	66.7%	82.2% 15.5 pts worse	79.7% 13 pts worse	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	15.4%	22.7% 7.3 pts better	23.9% 8.5 pts better	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-05-07 · Fire 2025-05-07

11 health deficiencies

Top issue: Resident Rights (3 deficiencies)

8 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 2 Health 2024-04-24 · Fire 2024-04-24

21 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

12 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2023-02-01 · Fire 2023-02-01

6 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-05-07

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-06-07

E · Potential for more than minimal harm 2025-05-07

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2025-06-07

E · Potential for more than minimal harm 2025-05-07

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-06-07

E · Potential for more than minimal harm 2025-05-07

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-07-18

E · Potential for more than minimal harm 2025-05-07

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-06-07

E · Potential for more than minimal harm 2025-05-07

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-06-07

E · Potential for more than minimal harm 2025-05-07

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2025-06-07

E · Potential for more than minimal harm 2025-05-07

K925 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that sources of ignition are removed from patients receiving respiratory therapy.

Corrected 2025-06-07

F · Potential for more than minimal harm 2024-04-24

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2024-05-24

F · Potential for more than minimal harm 2024-04-24

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-05-24

F · Potential for more than minimal harm 2024-04-24

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 2024-05-24

F · Potential for more than minimal harm 2024-04-24

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-08-15

F · Potential for more than minimal harm 2024-04-24

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-08-15

F · Potential for more than minimal harm 2024-04-24

K522 · Services Deficiencies

Fire Safety

Have an externally vented heating system.

Corrected 2024-05-24

F · Potential for more than minimal harm 2024-04-24

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-05-24

F · Potential for more than minimal harm 2024-04-24

K753 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of highly flammable decorations.

Corrected 2024-05-24

F · Potential for more than minimal harm 2024-04-24

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-05-24

E · Potential for more than minimal harm 2024-04-24

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2024-05-24

E · Potential for more than minimal harm 2024-04-24

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-05-24

E · Potential for more than minimal harm 2024-04-24

K919 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the use of electrical equipment.

Corrected 2024-05-24

E · Potential for more than minimal harm 2023-02-01

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2023-03-01

D · Potential for more than minimal harm 2023-02-01

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-03-01

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-05-07

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 2025-06-07

E · Potential for more than minimal harm 2025-05-07

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2025-06-07

D · Potential for more than minimal harm 2025-05-07

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2025-06-07

D · Potential for more than minimal harm 2025-05-07

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 2025-06-07

D · Potential for more than minimal harm 2025-05-07

F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Corrected 2025-06-07

D · Potential for more than minimal harm 2025-05-07

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2025-06-07

D · Potential for more than minimal harm 2025-05-07

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2025-06-07

D · Potential for more than minimal harm 2025-05-07

F657 · Resident Assessment and Care Planning Deficiencies

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 2025-06-07

D · Potential for more than minimal harm 2025-05-07

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-06-07

D · Potential for more than minimal harm 2025-05-07

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 2025-06-07

D · Potential for more than minimal harm 2025-05-07

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2025-06-07

D · Potential for more than minimal harm 2024-09-17

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-10-17

D · Potential for more than minimal harm 2024-09-17

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-10-17

D · Potential for more than minimal harm 2024-09-17

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 2024-10-17

F · Potential for more than minimal harm 2024-04-24

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 2024-05-24

F · Potential for more than minimal harm 2024-04-24

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-05-24

F · Potential for more than minimal harm 2024-04-24

F882 · Infection Control Deficiencies

Health

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Corrected 2024-05-24

E · Potential for more than minimal harm 2024-04-24

F657 · Resident Assessment and Care Planning Deficiencies

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 2024-05-24

E · Potential for more than minimal harm 2024-04-24