Map showing the location of DOOR COUNTY MEMORIAL HOSPITAL SNF in STURGEON BAY, Wisconsin
323 S 18TH AVE, STURGEON BAY, WI, 54235

Overall Score

CMS Five-Star Quality Rating
5/5Much above averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • WisconsinAbove 75% of peers321 rated homes · average 3.0★
  • United StatesAbove 80% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point4★+1.2 vs WI avg
  • StaffingCan add or remove a star5★+1.3 vs WI avg
  • Quality measuresCan add or remove a star5★+1.9 vs WI avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles4★Above 66% of peersWI avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover5★Above 71% of peersWI avg3.7★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 88% of peersWI avg3.1★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff4.78hrsAbove 79% of peersWI avg4.19Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only1.76hrsTop 3%WI avg0.96Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better49%Above only 44% of peersWI avg48%RN turnover27%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$0Above only 42% of peersWI avg$41,875Fines · denials0 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
8citations
3inspection dates
0actual harm (G–I)
0immediate jeopardy (J–L)
Jul 2, 2025most recent

Citations by monthJan 2024 – Jul 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Jul 2, 20254 citationsCycle 1worst E · no actual harm
  1. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Jul 23, 2025
  2. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 27, 2025
  3. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Jul 25, 2025
  4. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Jul 23, 2025
Feb 19, 20253 citationsCycle 1worst E · no actual harm
  1. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Feb 22, 2025
  2. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Mar 12, 2025
  3. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Feb 27, 2025
Jan 4, 20241 citationCycle 2worst E · no actual harm
  1. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Feb 12, 2024

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined4.78hrsAbove 79% of peers+0.59 vs WI avg
  • Registered nursesRN hours only1.76hrsTop 3%+0.80 vs WI avg
  • Licensed practical nursesLPN hours0.17hrs
  • Nurse aidesCNA hours2.85hrs
  • Weekend nursingAll staff on Saturdays and Sundays4.37hrs
  • Wisconsin average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better49%Above only 44% of peersWI avg 48%
  • RN turnoverRegistered nurses only27%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy32 certified beds · ~31 residents a day98%Top 2%WI avg 73%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $0In fines
  • 0Fines
  • 0Payment denials
  • $41,875WI avg in fines
Above only 42% of peersFewer fines than 42% of rated homes in Wisconsin

Actions on record

No fines or payment denialsNothing on record in the current reporting window. Wisconsin facilities average 1.2 penalties.

Ownership

As filed with CMS

Structure

Ownership type
Non profit - Corporation
Chain
Independent
Certification
Medicare and Medicaid
Location type
Rural
Ownership change
None in the last 12 months

People and entities on file

Operational or managerial control
  • St Vincent Hospital-Hospital Sisters-Third Order of St Francis
  • Jamie Alberts
  • Bradley Andreae
  • Maria Chona Antonio
  • Nancy Bohrman
  • Edgar Collison
  • Bernadette Conroy
  • Corwin Dahl
  • +15 more
Corporate directors
  • Jamie Alberts
  • Bradley Andreae
  • Edgar Collison
  • Bernadette Conroy
  • Corwin Dahl
  • Dorene Dempster
  • Robert Erickson
  • Erin Helgeson
  • +9 more
Corporate officers
  • Andrew Laluzerne
  • Brian Stephens

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 525377 · 323 S 18TH AVE, STURGEON BAY, WI, 54235.
  • Percentiles compare this facility with every rated nursing home in Wisconsin and Door County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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