01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-04-28 | 1 | 2026-04-28 | 2 |
| Cycle 2 | 2025-02-19 | 7 | 2025-02-19 | 3 |
| Cycle 3 | 2024-01-04 | 1 | 2024-01-04 | 9 |
CMS CCN 5253772026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Door County Memorial Hospital Snf
323 S 18Th Ave · Sturgeon Bay, WI 54235 · Door County
Certified beds32CMS provider file
Recent citation rows23current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
23 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 4 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-04-28 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2026-06-082026-04-28 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2026-06-222026-04-28 · FIREK0916Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Correction field: Deficient, Provider has date of correction · 2026-05-082025-07-02 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2025-07-23 · complaint2025-07-02 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2025-07-27 · complaint2025-07-02 · HEALTHF0610Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2025-07-25 · complaint2025-07-02 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2025-07-23 · complaint2025-02-19 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2025-02-222025-02-19 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2025-03-122025-02-19 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-02-272025-02-19 · FIREK0346Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Correction field: Deficient, Provider has date of correction · 2025-03-112025-02-19 · FIREK0353Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-03-262025-02-19 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2025-03-062024-01-04 · HEALTHF0610Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2024-02-12 · complaint2024-01-04 · FIREK0200Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Meet other general requirements.
Correction field: Deficient, Provider has date of correction · 2024-01-082024-01-04 · FIREK0281Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Install proper backup exit lighting.
Correction field: Waiver has been granted · 2024-06-112024-01-04 · FIREK0353Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-02-162024-01-04 · FIREK0362Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Correction field: Deficient, Provider has date of correction · 2024-01-082024-01-04 · FIREK0363Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2024-01-312024-01-04 · FIREK0372Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2024-01-082024-01-04 · FIREK0712Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2024-01-312024-01-04 · FIREK0753Severity E · pattern; potential for more than minimal harm
Miscellaneous Deficiencies
Have restrictions on the use of highly flammable decorations.
Correction field: Deficient, Provider has date of correction · 2024-01-082024-01-04 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Waiver has been granted · 2024-06-1103 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- ALBERTS, JAMIEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2021
- ANDREAE, BRADLEYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- COLLISON, EDGARIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 05/14/2025
- DAHL, CORWINIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2021
- DEMPSTER, DORENEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2019
- ERICKSON, ROBERTIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 05/15/2024
- HELGESON, ERINIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- HELM, PAULINEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2023
- JAROSH, JONATHANIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- KITCHENS, JOELIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2021
- RABAS, JEFFREYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2022
- REBHAN, JOSEPHIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2026
- RICHMOND, ANDREWIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 10/01/2017
- ST JEAN, MICHAELIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2025
- STERNARD, TAMMYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2025
- VICKMAN, PATRICIAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 10/01/2017
- ZIEGELBAUER, MARTHAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2022
- LALUZERNE, ANDREWIndividual · CORPORATE OFFICERNOT APPLICABLE · since 10/29/2018
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.78per resident day
RN hours1.59per resident day
Weekend nurse hours4.58per resident day
Staff turnover63.9%CMS reported field
06 / LOCAL RECORDS
Open the Sturgeon Bay ledger →