SNF
DOOR COUNTY MEMORIAL HOSPITAL SNF
CCN: 525377 · STURGEON BAY, WI 54235 · Door County
Hospital-based
Overview
- Address
- 323 S 18TH AVE, STURGEON BAY, WI 54235
- Phone
- 9207435566
- Certified beds
- 32
- Avg daily residents
- 31 (98% of beds filled)
- Ownership
- Non-profit corporation
- Provider type
- Medicare and Medicaid
- Medicare/Medicaid since
- 1984-10-01
- Setting
- Rural
5 /5
★★★★★
CMS Overall Rating
CMS 5-Star Ratings
CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.
Staffing & Workforce
Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.
| Role | Reported | Case-mix expected | Adjusted | Federal floor | |
|---|---|---|---|---|---|
| Total nurse All nursing staff combined: RN + LPN + Aide | 4.78 | 3.47 | 5.32 | ≥ 3.48 | |
| Registered Nurse (RN) Licensed RN hours. Strongest driver of clinical outcomes. | 1.76 | 0.61 | 1.95 | ≥ 0.55 | |
| Licensed Practical Nurse (LPN) LPN/LVN hours. Often handles medication administration. | 0.17 | 0.77 | 0.19 | — | |
| Nurse aide CNA hours. Bulk of direct resident care — bathing, feeding, mobility. | 2.85 | 2.09 | 3.17 | — | |
| Licensed (RN + LPN) Combined licensed nurse coverage. | 1.93 | — | — | — | |
| Physical therapist Rehabilitation therapist hours — important for post-acute / rehab admissions. | 0.01 | — | — | — |
Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.
Weekend staffing
Total nurse (weekend)
4.37
hrs / resident / day
RN (weekend)
1.37
hrs / resident / day
Total nurse (adjusted, weekend)
4.86
hrs / resident / day
Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.
Staff turnover
Total nursing staff turnover
48.8%
annual
RN turnover
26.7%
annual
Administrators departed
0
last 12 months
Resident acuity
Nursing Case-Mix Index
1.23
higher acuity than avg
Case-Mix Index Ratio
0.89
facility / state ratio
Health Inspections
CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.
| Cycle | Date | Total defs. | Standard | Complaint | Deficiency score | Revisits | Total score |
|---|---|---|---|---|---|---|---|
| Cycle 1 (most recent) | 2025-02-19 | 7 | 3 | 4 | 36 | 1 | 36 |
| Cycle 2/3 (prior) | 2024-01-04 | 1 | 1 | 1 | 8 | 1 | 8 |
Total weighted health score
29.0
lower is better
Deficiencies (8)
Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).
8 D/E/F Actual harm — potential for minor
| Tag | Description | Scope/Severity | Survey date | Corrected |
|---|---|---|---|---|
| 0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | 2025-07-02 | 2025-07-23 |
| 0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | 2025-07-02 | 2025-07-27 |
| 0610 | Respond appropriately to all alleged violations. | E | 2025-07-02 | 2025-07-25 |
| 0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | 2025-07-02 | 2025-07-23 |
| 0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | 2025-02-19 | 2025-02-22 |
| 0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | 2025-02-19 | 2025-03-12 |
| 0880 | Provide and implement an infection prevention and control program. | E | 2025-02-19 | 2025-02-27 |
| 0610 | Respond appropriately to all alleged violations. | E | 2024-01-04 | 2024-02-12 |
Ownership & Corporate Structure
Owner / manager organizations (1)
| Organization | Role | Association |
|---|---|---|
| ST VINCENT HOSPITAL-HOSPITAL SISTERS-THIRD ORDER OF ST FRANCIS | OPERATIONAL/MANAGERIAL CONTROL | since 10/28/2016 |
Owner / manager individuals (41)
| Name | Role | Association |
|---|---|---|
| ALBERTS, JAMIE | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2021 |
| ANDREAE, BRADLEY | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2024 |
| ANTONIO, MARIA CHONA | OPERATIONAL/MANAGERIAL CONTROL | since 07/01/2024 |
| BOHRMAN, NANCY | OPERATIONAL/MANAGERIAL CONTROL | since 07/01/2024 |
| COLLISON, EDGAR | OPERATIONAL/MANAGERIAL CONTROL | since 05/14/2025 |
| CONROY, BERNADETTE | OPERATIONAL/MANAGERIAL CONTROL | since 10/01/2019 |
| DAHL, CORWIN | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2021 |
| DEMPSTER, DORENE | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2019 |
| ERICKSON, ROBERT | OPERATIONAL/MANAGERIAL CONTROL | since 05/15/2024 |
| HELGESON, ERIN | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2024 |
| HELM, PAULINE | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2023 |
| JAROSH, JONATHAN | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2024 |
| KITCHENS, JOEL | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2021 |
| LALUZERNE, ANDREW | OPERATIONAL/MANAGERIAL CONTROL | since 10/29/2018 |
| RABAS, JEFFREY | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2022 |
| RICHMOND, ANDREW | OPERATIONAL/MANAGERIAL CONTROL | since 10/01/2017 |
| ST JEAN, MICHAEL | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2025 |
| STEPHENS, BRIAN | OPERATIONAL/MANAGERIAL CONTROL | since 01/06/2019 |
| STERNARD, TAMMY | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2025 |
| URBAN, CAROLINE | OPERATIONAL/MANAGERIAL CONTROL | since 07/01/2024 |
| VICKMAN, PATRICIA | OPERATIONAL/MANAGERIAL CONTROL | since 10/01/2017 |
| ZIEGELBAUER, MARTHA | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2022 |
| ALBERTS, JAMIE | CORPORATE DIRECTOR | since 01/01/2021 |
| ANDREAE, BRADLEY | CORPORATE DIRECTOR | since 01/01/2024 |
| COLLISON, EDGAR | CORPORATE DIRECTOR | since 05/14/2025 |
Showing 25 of 41 individuals. Full list in CSV.
Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.
Facility Features
- CCRC
- No
- Hospital-based
- Yes
- Resident / family council
- Resident
- Sprinkler systems
- Yes
- Abuse citation flag
- No
Methodology & sources
- Nursing Home Provider Info (
nh-provider-info), vintage 2026, downloaded 2026-04-14 , 14,703 rows. - Nursing Home Health Deficiencies (
nh-deficiencies), vintage 2026, downloaded 2026-04-14 , 418,972 rows. - Nursing Home Ownership (
nh-ownership), vintage 2026, downloaded 2026-04-14 , 160,393 rows.
All Data
Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.
Show 99 rows
| Source | Metric | Value | Raw key |
|---|---|---|---|
| Provider Information | Abuse Icon | N | Abuse Icon |
| Provider Information | Adjusted LPN Staffing Hours per Resident per Day | 0.19210 | Adjusted LPN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Nurse Aide Staffing Hours per Resident per Day | 3.17070 | Adjusted Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Adjusted RN Staffing Hours per Resident per Day | 1.95236 | Adjusted RN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Total Nurse Staffing Hours per Resident per Day | 5.31517 | Adjusted Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day | 4.85800 | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Administrator turnover footnote | — | Administrator turnover footnote |
| Provider Information | Automatic Sprinkler Systems in All Required Areas | Yes | Automatic Sprinkler Systems in All Required Areas |
| Provider Information | Average Number of Residents per Day | 31.4 | Average Number of Residents per Day |
| Provider Information | Average Number of Residents per Day Footnote | — | Average Number of Residents per Day Footnote |
| Provider Information | Case-Mix LPN Staffing Hours per Resident per Day | 0.77074 | Case-Mix LPN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Nurse Aide Staffing Hours per Resident per Day | 2.09469 | Case-Mix Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Case-Mix RN Staffing Hours per Resident per Day | 0.60751 | Case-Mix RN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Total Nurse Staffing Hours per Resident per Day | 3.47294 | Case-Mix Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day | 3.06103 | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Chain Average Health Inspection Rating | — | Chain Average Health Inspection Rating |
| Provider Information | Chain Average Overall 5-star Rating | — | Chain Average Overall 5-star Rating |
| Provider Information | Chain Average QM Rating | — | Chain Average QM Rating |
| Provider Information | Chain Average Staffing Rating | — | Chain Average Staffing Rating |
| Provider Information | Chain ID | — | Chain ID |
| Provider Information | Chain Name | — | Chain Name |
| Provider Information | City/Town | STURGEON BAY | City/Town |
| Provider Information | CMS Certification Number (CCN) | 525377 | CMS Certification Number (CCN) |
| Provider Information | Continuing Care Retirement Community | N | Continuing Care Retirement Community |
| Provider Information | County/Parish | Door | County/Parish |
| Provider Information | Date First Approved to Provide Medicare and Medicaid Services | 1984-10-01 | Date First Approved to Provide Medicare and Medicaid Services |
| Provider Information | Geocoding Footnote | — | Geocoding Footnote |
| Provider Information | Health Inspection Rating | 4 | Health Inspection Rating |
| Provider Information | Health Inspection Rating Footnote | — | Health Inspection Rating Footnote |
| Provider Information | Latitude | 44.8331 | Latitude |
| Provider Information | Legal Business Name | DOOR COUNTY MEMORIAL HOSPITAL | Legal Business Name |
| Provider Information | Location | 323 S 18TH AVE,STURGEON BAY,WI,54235 | Location |
| Provider Information | Long-Stay QM Rating | 5 | Long-Stay QM Rating |
| Provider Information | Long-Stay QM Rating Footnote | — | Long-Stay QM Rating Footnote |
| Provider Information | Longitude | -87.351 | Longitude |
| Provider Information | Most Recent Health Inspection More Than 2 Years Ago | N | Most Recent Health Inspection More Than 2 Years Ago |
| Provider Information | Number of administrators who have left the nursing home | 0 | Number of administrators who have left the nursing home |
| Provider Information | Number of Certified Beds | 32 | Number of Certified Beds |
| Provider Information | Number of Citations from Infection Control Inspections | — | Number of Citations from Infection Control Inspections |
| Provider Information | Number of Facilities in Chain | — | Number of Facilities in Chain |
| Provider Information | Number of Fines | 0 | Number of Fines |
| Provider Information | Number of Payment Denials | 0 | Number of Payment Denials |
| Provider Information | Nursing Case-Mix Index | 1.23031 | Nursing Case-Mix Index |
| Provider Information | Nursing Case-Mix Index Ratio | 0.89305 | Nursing Case-Mix Index Ratio |
| Provider Information | Overall Rating | 5 | Overall Rating |
| Provider Information | Overall Rating Footnote | — | Overall Rating Footnote |
| Provider Information | Ownership Type | Non profit - Corporation | Ownership Type |
| Provider Information | Physical Therapist Staffing Footnote | — | Physical Therapist Staffing Footnote |
| Provider Information | Processing Date | 2026-03-01 | Processing Date |
| Provider Information | Provider Address | 323 S 18TH AVE | Provider Address |
| Provider Information | Provider Changed Ownership in Last 12 Months | N | Provider Changed Ownership in Last 12 Months |
| Provider Information | Provider Name | DOOR COUNTY MEMORIAL HOSPITAL SNF | Provider Name |
| Provider Information | Provider Resides in Hospital | Y | Provider Resides in Hospital |
| Provider Information | Provider SSA County Code | 140 | Provider SSA County Code |
| Provider Information | Provider Type | Medicare and Medicaid | Provider Type |
| Provider Information | QM Rating | 5 | QM Rating |
| Provider Information | QM Rating Footnote | — | QM Rating Footnote |
| Provider Information | Rating Cycle 1 Health Deficiency Score | 36 | Rating Cycle 1 Health Deficiency Score |
| Provider Information | Rating Cycle 1 Health Revisit Score | 0 | Rating Cycle 1 Health Revisit Score |
| Provider Information | Rating Cycle 1 Number of Complaint Health Deficiencies | 4 | Rating Cycle 1 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 1 Number of Health Revisits | 1 | Rating Cycle 1 Number of Health Revisits |
| Provider Information | Rating Cycle 1 Number of Standard Health Deficiencies | 3 | Rating Cycle 1 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 1 Standard Survey Health Date | 2025-02-19 | Rating Cycle 1 Standard Survey Health Date |
| Provider Information | Rating Cycle 1 Total Health Score | 36 | Rating Cycle 1 Total Health Score |
| Provider Information | Rating Cycle 1 Total Number of Health Deficiencies | 7 | Rating Cycle 1 Total Number of Health Deficiencies |
| Provider Information | Rating Cycle 2 Number of Standard Health Deficiencies | 1 | Rating Cycle 2 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 2 Standard Health Survey Date | 2024-01-04 | Rating Cycle 2 Standard Health Survey Date |
| Provider Information | Rating Cycle 2/3 Health Deficiency Score | 8 | Rating Cycle 2/3 Health Deficiency Score |
| Provider Information | Rating Cycle 2/3 Health Revisit Score | 0 | Rating Cycle 2/3 Health Revisit Score |
| Provider Information | Rating Cycle 2/3 Number of Complaint Health Deficiencies | 1 | Rating Cycle 2/3 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 2/3 Number of Health Revisits | 1 | Rating Cycle 2/3 Number of Health Revisits |
| Provider Information | Rating Cycle 2/3 Total Health Score | 8 | Rating Cycle 2/3 Total Health Score |
| Provider Information | Rating Cycle 2/3 Total Number of Health Deficiencies | 1 | Rating Cycle 2/3 Total Number of Health Deficiencies |
| Provider Information | Registered Nurse hours per resident per day on the weekend | 1.36994 | Registered Nurse hours per resident per day on the weekend |
| Provider Information | Registered Nurse turnover | 26.7 | Registered Nurse turnover |
| Provider Information | Registered Nurse turnover footnote | — | Registered Nurse turnover footnote |
| Provider Information | Reported Licensed Staffing Hours per Resident per Day | 1.92897 | Reported Licensed Staffing Hours per Resident per Day |
| Provider Information | Reported LPN Staffing Hours per Resident per Day | 0.17280 | Reported LPN Staffing Hours per Resident per Day |
| Provider Information | Reported Nurse Aide Staffing Hours per Resident per Day | 2.85208 | Reported Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Reported Physical Therapist Staffing Hours per Resident Per Day | 0.01046 | Reported Physical Therapist Staffing Hours per Resident Per Day |
| Provider Information | Reported RN Staffing Hours per Resident per Day | 1.75617 | Reported RN Staffing Hours per Resident per Day |
| Provider Information | Reported Staffing Footnote | — | Reported Staffing Footnote |
| Provider Information | Reported Total Nurse Staffing Hours per Resident per Day | 4.78105 | Reported Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Short-Stay QM Rating | — | Short-Stay QM Rating |
| Provider Information | Short-Stay QM Rating Footnote | 2 | Short-Stay QM Rating Footnote |
| Provider Information | Special Focus Status | — | Special Focus Status |
| Provider Information | Staffing Rating | 5 | Staffing Rating |
| Provider Information | Staffing Rating Footnote | — | Staffing Rating Footnote |
| Provider Information | State | WI | State |
| Provider Information | Telephone Number | 9207435566 | Telephone Number |
| Provider Information | Total Amount of Fines in Dollars | 0.00 | Total Amount of Fines in Dollars |
| Provider Information | Total number of nurse staff hours per resident per day on the weekend | 4.36982 | Total number of nurse staff hours per resident per day on the weekend |
| Provider Information | Total Number of Penalties | 0 | Total Number of Penalties |
| Provider Information | Total nursing staff turnover | 48.8 | Total nursing staff turnover |
| Provider Information | Total nursing staff turnover footnote | — | Total nursing staff turnover footnote |
| Provider Information | Total Weighted Health Survey Score | 29.000 | Total Weighted Health Survey Score |
| Provider Information | Urban | N | Urban |
| Provider Information | With a Resident and Family Council | Resident | With a Resident and Family Council |
| Provider Information | ZIP Code | 54235 | ZIP Code |