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
Staffing
Hours and turnover
RN hours / resident day
1.01
Registered nurse staffing
LPN hours / resident day
0.56
Licensed practical nurse staffing
Aide hours / resident day
3.12
Nurse aide staffing
Weekend hours
4.40
Weekend nurse staffing
RN turnover
13%
Annual RN turnover
Total nurse turnover
39%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 | 34.9% |
21.1%
13.8 pts worse
|
16.3%
18.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 | 96.3% |
82.2%
14.1 pts better
|
79.7%
16.6 pts better
|
Short Stay · 2024Q3-2025Q2 |
| 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 |
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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