Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Door County Memorial Hospital Snf during CMS and state inspections, most recent first.
Two residents had repeated falls with inconsistent or missing fall interventions. One resident with severe cognitive impairment and multiple diagnoses continued to fall from a wheelchair, during self-transfers, and from bed, while fall assessments and the care plan did not consistently reflect interventions staff said were discussed or used. Another resident with a right BKA and intact cognition had a bolster bed intervention, but after the bolstered air mattress broke, the facility placed a regular mattress without bolstered edges in the bed, and the resident rolled out of bed and was sent to the ER for pain.
A resident with severe cognitive impairment sustained a skin tear that was not reported to the physician or POAHC until three days after the injury was identified. Staff interviews revealed inconsistent notification practices and a lack of clear policy regarding when to notify physicians about skin tears, despite facility policy requiring immediate notification for injuries that may require physician intervention.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Two residents with severe cognitive impairment were involved in an altercation that was observed by a CNA, but the incident and related interventions were not documented in their medical records. The care plans for both residents contained undated and unsigned handwritten changes, making it unclear if they were reviewed or revised after the event. The nursing home administrator confirmed the lack of documentation and was unable to verify care plan updates.
The facility failed to maintain an effective infection prevention and control program, as two residents were not included in the infection surveillance line list despite receiving antibiotics for UTIs. Additionally, improper handling of linens was observed, with an uncovered linen cart and dirty linens placed next to clean clothes in the laundry room, violating infection control protocols.
A resident with multiple health conditions experienced a significant weight gain, exceeding the 5-pound threshold set by the physician's order. Despite the requirement to notify the physician of such changes, the facility staff failed to do so, as confirmed by medical record reviews and staff interviews.
A resident with a history of chronic conditions experienced a weight gain that required an additional dose of bumetanide, as per physician's orders. However, the facility failed to administer the extra dose, as confirmed by the MAR and staff interviews.
Inconsistent fall interventions and mattress replacement led to repeated resident falls
Penalty
Summary
The facility did not ensure appropriate fall interventions were implemented or consistently care planned for two residents who experienced repeated falls. One resident had severe cognitive impairment with a BIMS score of 2 out of 15 and a history of cerebrovascular accident, Alzheimer’s dementia, rheumatoid arthritis, and a femur fracture from a fall. After returning from the hospital, this resident had multiple additional falls from a wheelchair, during self-transfers, and from bed. Some falls had interventions added, such as a bed alarm, wheelchair placement beside the bed, an anti-rollback device, a Broda Scoot wheelchair, and a wheelchair alarm, but several subsequent falls had no new interventions documented on the fall assessments or added to the care plan. Facility staff confirmed that some interventions were discussed in huddles or written by hand on paper care plans, but the typed care plan and Kardex did not consistently reflect those interventions, and staff could not identify interventions for several of the falls. The resident’s record also showed that after a fall on the floor by the bed, the bed alarm was not sounding and was found unplugged. The DON stated the alarm may have become unplugged when the bed was moved and that staff were discussing checking alarms each shift, but the Kardex reviewed by the surveyor did not contain that intervention. Staff interviews showed inconsistent knowledge about checking bed alarms and about the interventions in place for the resident. The record review and interviews showed that the resident continued to fall despite repeated events, while the documented fall assessments and care plan updates did not consistently match the interventions that staff said were being used. A second resident, who had a right below-knee amputation, diabetic neuropathy, type 2 diabetes, anxiety, and intact cognition, had a bolster bed intervention on the care plan for a history of rolling out of bed. After the resident’s bolstered air mattress broke, the facility replaced it with a regular air mattress without bolstered edges. The resident stated that the same day the replacement mattress was provided, the resident took a nap and fell out of bed. The resident was sent to the ER for pain, and the DON confirmed the facility should have provided a bolstered air mattress to replace the broken one and that the resident rolled out of bed after receiving the non-bolstered mattress.
Failure to Timely Notify Physician and POAHC of Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely notification of a change in condition to both the physician and the activated Power of Attorney for Healthcare (POAHC) for a resident with severely impaired cognition. The resident, who had diagnoses including myasthenia gravis, hypertension, heart failure, and depression, sustained a skin tear of unknown origin. The injury was identified by a registered nurse during a skin assessment, and a physician update statement was prepared several hours later. However, the physician and POAHC were not notified of the injury until three days after it was discovered. Staff interviews revealed inconsistent practices and a lack of clear policy regarding when to notify physicians about skin tears. Nursing staff indicated that the decision to notify was left to their discretion, often based on the perceived severity of the injury. The facility's policy required immediate notification of the physician and resident representative for accidents or injuries with the potential for requiring physician intervention, but this was not followed in the case of the skin tear. The nursing home administrator confirmed that there was no specific policy for reporting skin tears and acknowledged that notifications should occur immediately, typically within 24 hours.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Document Resident Altercation and Care Plan Updates
Penalty
Summary
The facility failed to ensure that medical records contained accurate and complete documentation for two residents following an altercation. On the date in question, a certified nursing assistant observed one resident in a wheelchair hitting another resident, who was in bed, on the legs. The incident was reported to the state agency, and subsequent actions included a nurse assessing the resident for injuries, notification of both residents' representatives, and informing local law enforcement and the physician. However, neither resident's medical record included documentation of the altercation, the interventions used to deescalate the situation, physical and psychosocial assessments, or notifications to representatives. Additionally, it was unclear whether care plans were reviewed or revised, as handwritten changes lacked dates and staff initials. Both residents involved had severe cognitive impairment, as indicated by their Brief Interview for Mental Status (BIMS) scores and diagnoses of Alzheimer's dementia and memory impairment. The lack of documentation extended to the care plans, which contained undated and unsigned handwritten interventions and changes. The nursing home administrator confirmed that the medical records did not contain documentation of the incident and was unable to verify if care plans had been reviewed or updated due to the absence of clear revision dates.
Infection Control Deficiencies in Surveillance and Linen Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of current and up-to-date infection surveillance for two residents. Resident 28 was not included on the facility's line list for a urinary tract infection (UTI) and the prescribed antibiotic, despite a urinalysis being ordered and an antibiotic being prescribed. Similarly, Resident 17 was not listed for antibiotic treatment for a UTI, even though the facility's antibiotic usage sheet indicated they received doxycycline and cefepime. The Director of Nursing confirmed that residents on antibiotics should be on the line list for surveillance, but neither resident was included. Additionally, the facility did not ensure proper infection control practices in the handling of linens. An uncovered linen cart was observed in the hallway, containing various clean linens, which was confirmed by a CNA to be against protocol. Furthermore, a bag of dirty linens was found on the clean side of the laundry room, next to folded clothes, which was acknowledged by a CNA as inappropriate. The Director of Nursing confirmed that clean and dirty areas in the laundry room should be kept separate to prevent cross-contamination.
Failure to Notify Physician of Significant Weight Change
Penalty
Summary
The facility failed to ensure proper notification to a physician as per the physician's order for a resident, identified as R17, who had a significant weight fluctuation. R17, who had intact cognition, was admitted with multiple diagnoses including edema, diabetes mellitus, hypertensive heart with chronic kidney disease, heart failure, end-stage renal disease, and COPD. The care plan for R17 included monitoring daily weights and notifying the physician if there was a weight change of more than 5 pounds. However, on February 3, 2025, R17 experienced a weight increase from 245.6 pounds to 251 pounds, exceeding the 5-pound threshold, but the physician was not notified as required. The surveyor's review of R17's medical records and interviews with staff confirmed the failure to notify the physician. Registered Nurse (RN)-C acknowledged the weight gain and verified that the treatment administration record required physician notification for such changes. Despite this, there was no documentation or evidence of communication with the physician regarding the weight increase. The Director of Nursing (DON)-B also confirmed that the physician notification was not documented, indicating a lapse in following the physician's order.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to ensure the accurate administration of medication for a resident, identified as R17, who was part of a sample of five residents. On a specific date, R17 was not administered an additional 1 mg dose of bumetanide, a diuretic medication, as per the physician's order. This order was contingent upon a weight increase of 4 pounds in one day. R17's weight increased by 4.48 pounds on that day, but the additional dose was not given, as confirmed by the medication administration record (MAR) and interviews with the nursing staff. R17 had a medical history that included edema, diabetes mellitus, hypertensive heart with chronic kidney disease with heart failure and end-stage renal disease, and chronic obstructive pulmonary disease (COPD). The resident's Minimum Data Set (MDS) assessment indicated intact cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The Director of Nursing and a registered nurse confirmed the oversight in medication administration, acknowledging that the additional dose of bumetanide was not administered despite the documented weight gain.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sturgeon Bay
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sturgeon Bay Health Services | 1.1 mi | ★★★★★ | 8 | 0 |
| Amethyst Health Of Algoma | 16.4 mi | ★★★★★ | 2 | 1 |
| Luther Home | 21.2 mi | ★★★★★ | 16 | 0 |
| Menominee Health Services | 23.8 mi | ★★★★★ | 3 | 0 |
| Rennes Health And Rehab Center-east | 24.6 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.