Cycle 1
Health 2024-10-30 · Fire 2024-10-30
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Sturgeon Bay, WI
Sturgeon Bay Health Services
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
200 N Seventh Ave, Sturgeon Bay, WI
(920) 743-6274
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
43
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
North Shore Healthcare
Operator or chain grouping
Approved since
1979-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
58 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 quality stars
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
0.71
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.51
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.22
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.44
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.22
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.46
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
0.74
CMS adjusted RN staffing hours
Adjusted total hours
3.60
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,058
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.87
Composite VBP score used to determine payment impact.
Payment multiplier
0.9836
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
3.05
Baseline 77.08% · Performance 58.54% · Measure score 3.05 · Achievement 1.26 · Improvement 3.05
Adjusted total nurse staffing
1.92
Baseline 2.63 hours · Performance 3.39 hours · Measure score 1.92 · Achievement 1.10 · Improvement 1.92
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.64% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 71 · Observed rate 11.27% · Lower 95% interval 6.94% |
| Discharge to community | 43.95% |
50.57%
6.6 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 38.6% · Lower 95% interval 33.54% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 75% |
95.27%
20.3 pts worse
|
Numerator 39 · Denominator 52 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 52 |
| Discharge self-care score | 65.52% |
53.69%
11.8 pts better
|
Numerator 19 · Denominator 29 |
| Discharge mobility score | 68.97% |
50.94%
18 pts better
|
Numerator 20 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 52 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 6% |
8.2%
2.2 pts worse
|
Numerator 3 · Denominator 50 |
| Staff flu vaccination coverage | 54% |
42%
12 pts better
|
Numerator 27 · Denominator 50 |
| Discharge function score | 65.52% |
56.45%
9.1 pts better
|
Numerator 19 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 51.61% |
25.2%
26.4 pts better
|
Numerator 16 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
95.7%
2.1 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.2% · Q3 97.1% · Q4 97.4% · 4Q avg 97.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.8% |
95.0%
8.2 pts worse
|
95.5%
8.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.8% |
3.2%
2.6 pts worse
|
3.3%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 8.3% · Q3 5.9% · Q4 5.1% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.8% |
5.0%
3.2 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 0.0% · Q4 3.0% · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
4.9%
0.4 pts worse
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 3.6% · Q3 7.1% · Q4 5.9% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.2% |
16.6%
1.6 pts worse
|
19.6%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 16.1% · Q3 17.2% · Q4 22.9% · 4Q avg 18.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.3% |
16.7%
0.4 pts better
|
16.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 16.7% · Q3 19.0% · Q4 18.8% · 4Q avg 16.3% · 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 | 15.1% |
21.1%
6 pts better
|
16.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.6% |
17.3%
1.3 pts worse
|
14.9%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 34.5% · Q3 3.6% · Q4 17.1% · 4Q avg 18.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.8% |
2.3%
4.5 pts worse
|
1.0%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 6.5% · Q3 9.3% · Q4 6.4% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.1% |
3.0%
0.1 pts worse
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 6.1% · Q3 3.0% · Q4 0.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.6% |
25.5%
0.1 pts worse
|
19.8%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 42.7% · Q3 12.8% · Q4 28.3% · 4Q avg 25.6% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
5.5%
0.6 pts better
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 0.0% · Q3 6.4% · Q4 5.0% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.4% |
86.8%
0.4 pts worse
|
81.7%
4.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.2% · Q2 85.4% · Q3 89.5% · Q4 84.4% · 4Q avg 86.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.5% |
15.0%
5.5 pts worse
|
12.0%
8.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.5% · Observed 24.4% · Expected 13.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.3%
0.6 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 3.7% · Q3 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.0% |
82.2%
4.2 pts worse
|
79.7%
1.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.2% |
22.7%
6.5 pts worse
|
23.9%
5.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.2% · Observed 34.1% · Expected 27.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-04 · Fire 2023-10-04
4 health deficiencies
Top issue: Administration (1 deficiency)
13 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2022-08-17 · Fire 2022-08-17
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-30
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-11-19
E · Potential for more than minimal harm
2024-10-30
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 2024-11-19
E · Potential for more than minimal harm
2024-10-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-19
E · Potential for more than minimal harm
2024-10-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-19
E · Potential for more than minimal harm
2024-10-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-19
E · Potential for more than minimal harm
2024-10-30
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-11-19
E · Potential for more than minimal harm
2024-10-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-11-19
D · Potential for more than minimal harm
2024-10-30
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-11-19
F · Potential for more than minimal harm
2023-10-04
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2023-11-03
F · Potential for more than minimal harm
2023-10-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-11-29
F · Potential for more than minimal harm
2023-10-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-11-16
F · Potential for more than minimal harm
2023-10-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-10-04
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 2023-11-16
E · Potential for more than minimal harm
2023-10-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-28
E · Potential for more than minimal harm
2023-10-04
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-10-04
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-10-04
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-10-04
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-04
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-04
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-11-03
E · Potential for more than minimal harm
2022-08-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-19
E · Potential for more than minimal harm
2022-08-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-19
E · Potential for more than minimal harm
2022-08-17
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2022-08-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-01
G · Actual harm
2025-01-22
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 2025-02-13
D · Potential for more than minimal harm
2024-10-30
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2024-11-25
D · Potential for more than minimal harm
2024-10-30
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-25
D · Potential for more than minimal harm
2024-10-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-11-25
D · Potential for more than minimal harm
2024-10-30
F690 · Quality of Life and Care Deficiencies
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 2024-11-22
D · Potential for more than minimal harm
2024-10-30
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-11-25
F · Potential for more than minimal harm
2023-10-04
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 2023-10-27
D · Potential for more than minimal harm
2023-10-04
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-10-30
C · Minimal harm
2023-10-04
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2023-10-27
D · Potential for more than minimal harm
2022-08-17
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-09-06
D · Potential for more than minimal harm
2022-08-17
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 2022-09-09
Penalties and ownership
What sits behind the stars
Ownership
North Shore Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Baumann, Troy
5% Or Greater Direct Ownership Interest · Individual
Baumann, Troy
Operational/Managerial Control · Individual
Baumann, Troy
Corporate Officer · Individual
Hoehn, Jeffrey
5% Or Greater Direct Ownership Interest · Individual
Hoehn, Jeffrey
Operational/Managerial Control · Individual
Hoehn, Jeffrey
Corporate Officer · Individual
North Shore Healthcare LLC
Operational/Managerial Control · Organization
Nshc Wisconsin LLC
5% Or Greater Direct Ownership Interest · Organization
Nshc Wisconsin LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Door County Memorial Hospital SNF
Sturgeon Bay, WI
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Amethyst Health Of Algoma
Algoma, WI
2-star overall rating with 2-star inspections with $8,152 in total fines with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Luther Home
Marinette, WI
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Jump out