Cycle 1
Health 2025-04-02 · Fire 2025-04-02
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Kaukauna, WI
St Paul Elder Services, Inc
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
316 East 14th Street, Kaukauna, WI
(920) 766-6020
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
105
Certified beds
Average residents
100
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-07-01
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
Hours and turnover
RN hours / resident day
1.01
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.56
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.12
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.69
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.40
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.86
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.93
CMS adjusted RN staffing hours
Adjusted total hours
4.34
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
511
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
68.54
Composite VBP score used to determine payment impact.
Payment multiplier
1.0216
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 17.62% · Performance 16.22% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
8.57
Baseline 7.71% · Performance 5.27% · Measure score 8.57 · Achievement 8.57 · Improvement 8.47
Total nurse turnover
5.73
Baseline 41.25% · Performance 40.27% · Measure score 5.73 · Achievement 5.73 · Improvement 0.10
Adjusted total nurse staffing
3.12
Baseline 4.08 hours · Performance 3.97 hours · Measure score 3.12 · Achievement 3.12 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.77% |
10.72%
2 pts better
|
No Different than the National Rate · Eligible stays 171 · Observed rate 5.26% · Lower 95% interval 5.8% |
| Discharge to community | 58.98% |
50.57%
8.4 pts better
|
No Different than the National Rate · Eligible stays 156 · Observed rate 57.05% · Lower 95% interval 49.67% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.78% |
95.27%
3.5 pts better
|
Numerator 81 · Denominator 82 |
| Falls with major injury | 2.44% |
0.77%
1.7 pts worse
|
Numerator 2 · Denominator 82 |
| Discharge self-care score | 57.14% |
53.69%
3.5 pts better
|
Numerator 36 · Denominator 63 |
| Discharge mobility score | 58.73% |
50.94%
7.8 pts better
|
Numerator 37 · Denominator 63 |
| Pressure ulcers or injuries, new or worsened | 4.88% |
2.29%
2.6 pts worse
|
Numerator 4 · Denominator 82 · Adjusted rate 5.15% |
| Healthcare-associated infections requiring hospitalization | 5.27% |
7.12%
1.9 pts better
|
No Different than the National Rate · Eligible stays 91 · Observed rate 1.1% · Lower 95% interval 2.85% |
| Staff COVID-19 vaccination coverage | 12.83% |
8.2%
4.6 pts better
|
Numerator 53 · Denominator 413 |
| Staff flu vaccination coverage | 89.44% |
42%
47.4 pts better
|
Numerator 525 · Denominator 587 |
| Discharge function score | 71.43% |
56.45%
15 pts better
|
Numerator 45 · Denominator 63 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 55 · Denominator 55 |
| Resident COVID-19 vaccinations up to date | 44.23% |
25.2%
19 pts better
|
Numerator 23 · Denominator 52 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.6
0.3 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.5 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.2
0.8 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
95.7%
4 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.6% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
95.0%
3.8 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.1% |
3.2%
0.9 pts worse
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 5.4% · Q3 4.2% · Q4 2.8% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.8% |
5.0%
1.2 pts better
|
11.4%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 5.9% · Q3 1.6% · Q4 0.0% · 4Q avg 3.8% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
4.9%
1.4 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 5.7% · Q3 1.7% · Q4 1.9% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.4% |
16.6%
12.8 pts worse
|
19.6%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 28.1% · Q3 32.2% · Q4 29.6% · 4Q avg 29.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.7% |
16.7%
3 pts worse
|
16.7%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 18.2% · Q3 23.4% · Q4 18.5% · 4Q avg 19.7% · 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 | 34.9% |
21.1%
13.8 pts worse
|
16.3%
18.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 50.2% · Q3 30.9% · Q4 23.3% · 4Q avg 34.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.8% |
17.3%
10.5 pts worse
|
14.9%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.8% · Q2 22.9% · Q3 33.3% · Q4 20.8% · 4Q avg 27.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
2.3%
2 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.2% |
3.0%
2.2 pts worse
|
1.7%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 7.0% · Q3 6.9% · Q4 1.4% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.3% |
25.5%
2.8 pts worse
|
19.8%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.1% · Q2 26.5% · Q3 28.9% · Q4 19.1% · 4Q avg 28.3% |
| Percentage of long-stay residents with pressure ulcers | 7.3% |
5.5%
1.8 pts worse
|
5.1%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 5.7% · Q3 7.8% · Q4 8.5% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
86.8%
11.1 pts better
|
81.7%
16.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 97.8% · Q3 98.4% · Q4 97.9% · 4Q avg 97.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.8% |
15.0%
2.2 pts better
|
12.0%
0.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.8% · Observed 12.2% · Expected 10.6% · 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 0.8% · Q2 1.6% · Q3 1.7% · Q4 1.6% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.3% |
82.2%
14.1 pts better
|
79.7%
16.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.2% |
22.7%
8.5 pts better
|
23.9%
9.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.2% · Observed 13.4% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-20 · Fire 2024-03-20
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-02-22 · Fire 2023-02-22
0 health deficiencies
No concentrated health issue counts in this cycle.
13 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-04-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-04-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-04-02
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-25
C · Minimal harm
2025-04-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-25
F · Potential for more than minimal harm
2024-03-20
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-04-15
F · Potential for more than minimal harm
2024-03-20
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-04-15
F · Potential for more than minimal harm
2024-03-20
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-15
F · Potential for more than minimal harm
2024-03-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-03-20
K222 · Egress Deficiencies
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 2024-04-15
D · Potential for more than minimal harm
2024-03-20
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 2024-04-15
D · Potential for more than minimal harm
2024-03-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-15
F · Potential for more than minimal harm
2023-02-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-17
F · Potential for more than minimal harm
2023-02-22
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-03-17
F · Potential for more than minimal harm
2023-02-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-17
F · Potential for more than minimal harm
2023-02-22
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-03-17
F · Potential for more than minimal harm
2023-02-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-17
E · Potential for more than minimal harm
2023-02-22
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2023-03-17
E · Potential for more than minimal harm
2023-02-22
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-03-17
E · Potential for more than minimal harm
2023-02-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-17
E · Potential for more than minimal harm
2023-02-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-02-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-02-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-20
D · Potential for more than minimal harm
2023-02-22
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-02-22
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-03-17
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-16
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-06-17
E · Potential for more than minimal harm
2025-04-02
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 2025-04-25
D · Potential for more than minimal harm
2025-04-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-04-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-28
D · Potential for more than minimal harm
2025-04-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-04-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-25
D · Potential for more than minimal harm
2024-09-26
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 2024-10-11
Penalties and ownership
What sits behind the stars
Ownership
Abel, Jackie
Operational/Managerial Control · Individual
Abel, Jackie
Corporate Director · Individual
Acker, Charleen
Operational/Managerial Control · Individual
Acker, Charleen
Corporate Director · Individual
Amergis Healthcare Staffing, Inc
Operational/Managerial Control · Organization
Brady, Nicole
Operational/Managerial Control · Individual
Brady, Nicole
Corporate Director · Individual
Davis Clinical Consulting
Operational/Managerial Control · Organization
Eiting, Clay
Operational/Managerial Control · Individual
Eiting, Clay
Corporate Director · Individual
Franciscan Sisters Of Christian Charity Sponsored Ministries, Inc.
Operational/Managerial Control · Organization
Gage, Michael
Operational/Managerial Control · Individual
Gage, Michael
Corporate Director · Individual
Hietpas, Pat
Operational/Managerial Control · Individual
Hietpas, Pat
Corporate Director · Individual
Kienert, Kelsey
Operational/Managerial Control · Individual
Kohlmann, Joellen
Operational/Managerial Control · Individual
Kohlmann, Joellen
Corporate Director · Individual
Lemke, Karmen
Operational/Managerial Control · Individual
Lemke, Karmen
Corporate Director · Individual
Mashl, Megan
Operational/Managerial Control · Individual
Neville, Ryan
Operational/Managerial Control · Individual
P&M Holding Group Llp
Operational/Managerial Control · Organization
Prn Health Services, Inc.
Operational/Managerial Control · Organization
Sabin-Wilson, Lisa
Operational/Managerial Control · Individual
Schroeder, Amber
Operational/Managerial Control · Individual
Schroeder, Amber
Corporate Officer · Individual
Vandehey, Paula
Operational/Managerial Control · Individual
Vandehey, Paula
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Little Chute Health Services
Little Chute, WI
2-star overall rating with 1-star inspections with $30,109 in total fines with 12 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Edenbrook Of Appleton North
Appleton, WI
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Rennes Health And Rehab Center- Appleton
Appleton, WI
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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