Door County Memorial Hospital SNFCMS ratings, inspections and fines
- Address
- 323 S 18th Ave, Sturgeon Bay, WI 54235
- CCN
- 525377
- Ownership type
- Non-profit, corporation
- Certified beds
- 32
- Chain
- None in the CMS record
- Residents per day
- 31
- CMS flags
- None in the CMS record
The watch list stays in this browser. After each CMS update, it shows the values that changed at the homes on the list.
CMS gives Door County Memorial Hospital SNF an overall rating of 5 of 5 stars. The last standard survey was on 28 Apr 2026. The latest survey cycle has 1 health citation. The median for nursing homes in Wisconsin is 7. CMS lists no fines for this home in its penalties file.
Facilities may see a change in their overall rating for a number of reasons. Since the overall rating is based on three individual domains, a change in any one of the domains can affect the overall rating. Any new data for a nursing home could potentially change a star rating domain.
Centers for Medicare & Medicaid Services, Five-Star Quality Rating System: Technical Users' Guide, July 2026. CMS processed this record on .
Since the last CMS update
The site has no recorded change for this home. In each CMS update, the site compares the ratings, the penalties and the citations of each home.
Ratings
CMS gives each home 1 to 5 stars for health inspections, for staffing and for quality measures, and one overall rating.
| Rating (1 to 5 stars) | This home | Door County median | Wisconsin median | US average (CMS) |
|---|---|---|---|---|
| Overall rating | 5 | 3.0 | 3.0 | 3.0 |
| Health inspection rating | 4 | 4.0 | 3.0 | 2.8 |
| Staffing rating | 5 | 3.0 | 4.0 | 2.9 |
| Quality measure rating | 5 | 3.0 | 3.0 | 3.6 |
A median is the middle value of the homes in the group: 3 homes in the county, 323 homes in the state. What the CMS star ratings measure
Citations by survey cycle
CMS keeps the last three cycles, and cycle 1 is the latest. A cycle has one standard survey. Citations from complaint and infection control inspections go into cycles of 12 months.
| Survey cycle | Standard survey | Citations | Wisconsin median |
|---|---|---|---|
| Cycle 1 (latest) | 28 Apr 2026 | 1 | 7 |
| Cycle 2 | 19 Feb 2025 | 7 | 7 |
| Cycle 3 | No date | 1 | 6 |
Health citations
The record of one deficiency in an inspection. One inspection can give many citations.
Scope and severity. A letter from A to L on each citation. Scope is the number of residents that the deficiency affected. Severity is the level of harm.
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy to resident health or safety | J0 | K0 | L0 |
| Actual harm that is not immediate jeopardy | G0 | H0 | I0 |
| No actual harm, potential for more than minimal harm | F0 | ||
| No actual harm, potential for minimal harm | A0 | B0 | C0 |
Survey cycle 1 (latest): 1 citation
Standard survey of this cycle: .
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 28 Apr 2026 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard survey | 8 Jun 2026 |
Survey cycle 2: 7 citations
Standard survey of this cycle: .
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 2 Jul 2025 | F0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | Complaint investigation | 23 Jul 2025 |
| 2 Jul 2025 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint investigation | 27 Jul 2025 |
| 2 Jul 2025 | F0610 | Respond appropriately to all alleged violations. | E | Complaint investigation | 25 Jul 2025 |
| 2 Jul 2025 | F0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | Complaint investigation | 23 Jul 2025 |
| 19 Feb 2025 | F0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | Standard survey | 22 Feb 2025 |
| 19 Feb 2025 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Standard survey | 12 Mar 2025 |
| 19 Feb 2025 | F0880 | Provide and implement an infection prevention and control program. | E | Standard survey | 27 Feb 2025 |
Survey cycle 3: 1 citation
The CMS provider file has no standard survey date for this cycle.
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 4 Jan 2024 | F0610 | Respond appropriately to all alleged violations. | E | Complaint investigation | 12 Feb 2024 |
The requirement text is the CMS summary of the F-tag. It is not the report of the surveyor. How to read an inspection report
Penalties
A fine, or a payment denial: a period in which Medicare or Medicaid does not pay for new admissions. The CMS penalties file holds three years.
CMS lists no fine and no payment denial for this home in its penalties file.
Staffing
Hours per resident per day. The nurse hours for one resident on an average day. CMS calculates the figure from the hours that the home reports for a quarter.
| Staff | This home | Wisconsin median | Wisconsin average (CMS) |
|---|---|---|---|
| All nurse staff | 4.78 | 4.00 | 4.21 |
| Registered nurses (RN) | 1.59 | 0.90 | 0.99 |
| Licensed practical nurses (LPN) | 0.41 | 0.64 | |
| Nurse aides | 2.79 | 2.58 | |
| All nurse staff, weekends | 4.58 | 3.60 | 3.77 |
- Nurse staff turnover in a year
- 63.9%
- Nurse staff turnover, Wisconsin median
- 46.2%
- RN turnover in a year
- 38.9%
- Administrators who left in a year
- 0
Homes report the hours to CMS in the Payroll-Based Journal.
Quality measures
A figure that CMS calculates from the assessments of residents. One example is the percentage of long-stay residents with a fall and a major injury.
| Measure (CMS text) | Residents | This home | Wisconsin median | US median |
|---|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 11.8% | 15.4% | 12.6% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 1.7% | 1.5% | 0.3% |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.0% | 2.3% | 0.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 5.1% | 3.0% | 2.8% |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 14.2% | 16.8% | 12.5% |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 3.9% | 4.4% | 4.2% |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 8.9% | 14.4% | 13.4% |
For each measure in this table, CMS gives more points in the quality measure rating for a lower percentage. The site calculates the medians from the CMS file. What the CMS star ratings measure
Ownership
An organisation in the CMS ownership file. CMS records its role, for example an ownership interest, operational or managerial control, or a mortgage interest.
- Ownership type
- Non-profit, corporation
- Setting
- In a hospital
- Legal business name
- Door County Memorial Hospital
| Organisation | Role in the CMS record | Interest | Since |
|---|---|---|---|
| St Vincent Hospital-Hospital Sisters-Third Order of St Francis | Operational/managerial control | 28 Oct 2016 | |
| St Vincent Hospital-Hospital Sisters-Third Order of St Francis | Adp of the snf | 14 Feb 2025 |
The site shows organisations only. It does not show the names of persons.
Other homes in Door County
| Nursing home | City | Overall rating | Citations, latest cycle | Fines | Last standard survey | |
|---|---|---|---|---|---|---|
| Sturgeon Bay Health Services | Sturgeon Bay | 3 of 5 | 2 | $0 | 4 Mar 2026 | |
| Serenity Spring Senior Living at Scandia Village | Sister Bay | 2 of 5 | 16 | $0 | 3 Jun 2026 |
Official channels
- Care Compare record of this nursing homeMedicare.gov. The official CMS record of this home.
- Contact information for State Survey AgenciesCMS. The web address and the telephone number of the State Survey Agency of each state. These agencies investigate complaints about nursing homes.
- Filing a complaintMedicare.gov. The page names the State Survey Agency as the place for a complaint about nursing home care or facility conditions.
- Eldercare LocatorAdministration for Community Living. A public service that connects older adults and their families to local services. Telephone: 1-800-677-1116.
Cite this page
Centers for Medicare & Medicaid Services, Care Compare. Record of Door County Memorial Hospital SNF (CCN 525377). Data processed 1 Aug 2026. Elder Care Record, https://eldercarerecord.com/facility/door-county-memorial-hospital-snf-sturgeon-bay-wi-525377/
Provenance
- Licence
- US government work, public domain
- CMS processed the data on
A program makes this page from the CMS files, and the same files always give the same text. How the site makes the figures. Report an error.
Questions
- When was Door County Memorial Hospital SNF last inspected?
- The latest inspection with a citation in the CMS record was on 28 Apr 2026. It was a standard survey. It gave 1 citation. The standard survey before the last one was on 19 Feb 2025.
- Who operates Door County Memorial Hospital SNF?
- The CMS record gives the ownership type as non-profit, corporation. CMS lists no chain for the home. The CMS ownership file names St Vincent Hospital-Hospital Sisters-Third Order of St Francis for operational or managerial control. This site does not show the names of persons.
- Is Door County Memorial Hospital SNF a Special Focus Facility?
- No. The CMS provider file lists no Special Focus status for this home. CMS lists 2 homes in Wisconsin as Special Focus Facilities and 10 as candidates.
- Where does the data on this page come from?
- The data comes from the CMS Care Compare files for nursing homes. CMS processed the files on 1 Aug 2026. The Care Compare record on Medicare.gov is the official record of the home.