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

Chain footprint

12 facilities

Chain averages 2 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.98

Registered nurse staffing · state 0.97 · national 0.68

LPN hours / resident day

0.59

Licensed practical nurse staffing · state 0.64 · national 0.87

Aide hours / resident day

2.09

Nurse aide staffing · state 2.59 · national 2.35

Total nurse hours

3.66

All reported nurse hours · state 4.20 · national 3.89

Licensed hours

1.57

RN + LPN hours · state 1.60 · national 1.54

Weekend hours

3.02

Weekend nurse staffing · state 3.72 · national 3.43

Weekend RN hours

0.35

Weekend registered nurse coverage · state 0.66 · national 0.47

Physical therapist

0.13

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

1.24

CMS adjusted RN staffing hours

Adjusted total hours

4.63

CMS adjusted total nurse staffing hours

Case-mix index

1.08

Higher values indicate more complex resident acuity

RN turnover

63%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

77%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

7,646

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

29.16

Composite VBP score used to determine payment impact.

Payment multiplier

0.9853

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

Baseline 73.81% · Performance 80.85% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

5.83

Baseline 3.36 hours · Performance 4.74 hours · Measure score 5.83 · Achievement 5.83 · Improvement 5.19

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays 24 · 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 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	0.8	1.02 0.2 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 25 · Denominator 25
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 25
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 25 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 84
Staff flu vaccination coverage	77.38%	42% 35.4 pts better	Numerator 65 · Denominator 84
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.

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 · Adjusted 0.6 · Observed 0.6 · Expected 1.9 · Used in QM five-star
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 · Adjusted 4.1 · Observed 3.9 · Expected 1.6 · Used in QM five-star
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	96.9%	95.0% 1.9 pts better	95.5% 1.4 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 96.9%
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 · Q1 3.6% · Q2 3.4% · Q3 6.1% · Q4 6.2% · 4Q avg 4.9% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 6.9% · 4Q avg 1.9%
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 · Q1 8.0% · Q2 4.0% · Q3 0.0% · Q4 3.6% · 4Q avg 3.7%
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 · Q1 23.1% · Q2 23.1% · Q3 17.2% · Q4 32.1% · 4Q avg 23.9%
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 · Q3 25.0% · Q4 19.0% · 4Q avg 22.7% · 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	23.9%	21.1% 2.8 pts worse	16.3% 7.6 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 23.9% · Used in QM five-star
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 · Q1 7.7% · Q2 23.1% · Q3 41.4% · Q4 23.1% · 4Q avg 24.3% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 3.4% · 4Q avg 1.6% · Used in QM five-star
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 · Q1 3.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star
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 · Q1 22.7% · Q2 19.6% · Q3 38.7% · Q4 27.3% · 4Q avg 27.6%
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 · Q1 5.3% · Q2 9.3% · Q3 12.8% · Q4 4.5% · 4Q avg 8.1% · Used in QM five-star
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 · Q1 96.9% · Q2 94.6% · Q3 95.1% · Q4 91.8% · 4Q avg 94.3%
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 · Adjusted 15.5% · Observed 13.6% · Expected 9.8% · 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 · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star
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 · 4Q avg 66.7%
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 · Adjusted 15.4% · Observed 13.6% · Expected 21.1% · Used in QM five-star

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