Average — CMS composite of the measures below.
The next survey window likely opens around February 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 Sturgeon Bay Health Services during CMS and state inspections, most recent first.
A resident with bipolar disorder, generalized anxiety disorder, and ADD had a PASRR Level I Screen showing a 30-day exemption, but the facility did not complete a new Level I Screen or a Level II evaluation after the exemption expired. The SSD said the resident was expected to stay only 30 days for rehab and then discharge to ALF, and the NHA later acknowledged the required PASRR screens were not completed.
A resident with rheumatoid arthritis and chronic pain had orders for scheduled and PRN tramadol, but multiple doses were missed or not documented when the medication ran out. MAR review, contingency stock records, and staff interviews showed the refill process was delayed, some prescriptions were sent to the wrong pharmacy, and nurses did not consistently obtain the medication from contingency stock even though it was available.
A resident on anticoagulant medication was not safely transferred with a mechanical lift, resulting in significant bruising and acute anemia. Despite therapy staff recommending a Hoyer lift, the care plan and CNA Kardex were not updated, leading to continued use of an inappropriate sit-to-stand lift. This oversight resulted in the resident's hospitalization due to severe bruising and anemia.
A facility failed to obtain court-ordered protective placement for a resident with a legal guardian, whose stay exceeded 90 days. The resident, diagnosed with Down syndrome and severely impaired cognition, had a guardianship since 2009, but lacked the required protective placement paperwork. The social worker was unaware of the requirement, which was confirmed by Adult Protective Services.
A resident with severe cognitive impairment and multiple medical conditions was hospitalized due to inadequate nutrition and hydration management. The facility failed to develop a comprehensive care plan addressing these needs, despite significant weight loss and hospitalization for related issues. Interviews with staff and the resident's guardian confirmed the absence of a formal care plan.
A resident with moderate cognitive impairment and multiple health conditions did not receive routine nail care, leading to discomfort from overgrown and damaged nails. Despite requiring assistance for all activities of daily living, the facility staff failed to provide nail care during weekly showers, as confirmed by interviews with CNAs and the Director of Nursing.
A resident with a Foley catheter was observed with the catheter drainage bag and tubing in contact with the floor, contrary to proper care practices. The facility's Catheter Care policy lacked guidance on the correct positioning of catheter equipment. Staff interviews confirmed that catheter bags and tubing should not touch the floor, yet the deficiency was observed, highlighting a lapse in care.
A resident at risk for nutritional decline did not receive prescribed large meal portions and nutritional supplements upon returning from a hospital stay. The facility lacked policies for nutrition and re-admission orders, leading to a deficiency in care.
PASRR Screening Not Completed After 30-Day Exemption Expired
Penalty
Summary
The facility did not provide PASRR services for one resident, R8, after the resident’s 30-day exemption expired. R8 was admitted with diagnoses including bipolar disorder, generalized anxiety disorder, and attention deficit disorder, and the medical record also showed a BIMS score of 11 out of 15, indicating moderately impaired cognition. R8 was his/her own decision maker. The record contained a PASRR Level I Screen that indicated a 30-day exemption, but the facility did not submit a new PASRR Level I Screen when that exemption expired and did not complete a PASRR Level II Screen. Surveyor review and staff interviews confirmed the omission. The Social Services Director stated the Level I Screen was not completed because R8 was expected to stay only 30 days for rehabilitation and then discharge to an assisted living facility. The Nursing Home Administrator later acknowledged that the required PASRR Level I and Level II screens after the exemption expired were not completed as required. The Social Services Director then confirmed that the Level I Screen following expiration of the 30-day exemption and the subsequent Level II Screen were not completed.
Missed Tramadol Doses Due to Delayed Refill and Contingency Stock Use
Penalty
Summary
The facility did not ensure accurate acquisition and administration of tramadol for one resident with rheumatoid arthritis and intact cognition. The resident had orders for tramadol 50 mg by mouth every 6 hours as needed for pain and 50 mg every night shift between 3:00 AM and 4:00 AM. The resident’s care plan identified pain related to rheumatoid arthritis and included interventions to administer pain medication per MD orders and monitor effectiveness. The resident reported chronic pain, with pain rated 6 out of 10 when tramadol was not given and 4 out of 10 when it was administered. Record review showed the resident’s tramadol was last administered on 2/27/26 at 3:20 AM, and the medication then ran out. Staff interviews indicated that when medication is low, it should be reordered through the electronic medical record, and if not available in the cart, staff should remove it from contingency stock. The facility’s contingency stock included tramadol 50 mg tablets, but the resident did not receive eight doses when the medication was unavailable and/or not removed from contingency stock. The MAR showed missed or undocumented doses for the scheduled 3:00 AM to 4:00 AM administration and bedtime dose across multiple days, including entries coded as other/see progress note or with no documentation. Surveyor review of the contingency stock report showed tramadol was removed from contingency on several occasions, including one dose removed on 2/26/26 for the 3:00 AM to 4:00 AM dose, a PRN bedtime dose on 3/3/26, and a 3:00 AM to 4:00 AM dose on 3/4/26. However, the MAR did not consistently document these administrations, and surveyor noted tramadol tablets were available in contingency stock during the missed administration times. Staff interviews confirmed the medication had run out, that refill requests were delayed or sent to the wrong pharmacy, and that nurses were aware tramadol was in contingency but did not use the contingency dispensing machine for the resident’s missed doses.
Failure to Ensure Safe Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, identified as R1, using a mechanical lift, which resulted in significant bruising and acute anemia. R1, who was on anticoagulant medication, was initially assessed as a pivot transfer with two staff and a gait belt. However, therapy staff later recommended a sit-to-stand lift, and subsequently, a full body (Hoyer) lift due to safety concerns. Despite these recommendations, the care plan and CNA Kardex were not updated in a timely manner, leading to continued use of the sit-to-stand lift, which was inappropriate for R1's condition. R1 experienced multiple unsafe transfers with the sit-to-stand lift, as documented by therapy and nursing staff. These transfers caused significant bruising on R1's left upper arm, shoulder, and torso, which was not promptly reported to a physician. R1's condition worsened, resulting in severe acute anemia and hospitalization, where a significant hematoma was discovered. The facility's failure to update the care plan and Kardex, and to monitor R1's condition adequately, contributed to the adverse outcome. Interviews with staff revealed that there was a lack of communication and follow-through regarding changes in R1's transfer status. Therapy staff completed a functional maintenance plan recommending the use of a Hoyer lift, but this was not communicated effectively to nursing staff, who continued to use the sit-to-stand lift. The facility's policies on high-risk medications and mechanical lift use were not adhered to, leading to R1's injury and subsequent hospitalization.
Failure to Obtain Court-Ordered Protective Placement
Penalty
Summary
The facility failed to ensure that a court-ordered protective placement was obtained for a resident with a legal guardian, whose stay at the nursing home exceeded 90 days. The resident, who was admitted with a diagnosis of Down syndrome and had severely impaired cognition, had a guardianship in place since 2009. However, the facility did not have the necessary annual protective placement paperwork in the resident's medical record, as required by State Statute Chapter 55.03(4). During the survey, the social worker acknowledged that the resident was not protectively placed and had been residing at the facility for an extended period. The social worker was unaware of the requirement for protective placement for residents with guardianship entering long-term care. The social worker contacted Adult Protective Services, who confirmed that protective placement was necessary for residents with guardianship in facilities with more than 16 beds, regardless of how the guardianship was initially sought.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident, identified as R5, who was hospitalized due to not eating or drinking. R5 was admitted with multiple diagnoses, including cerebrovascular accident, hemiplegia, hemiparesis, weakness, and diabetes, and had a severe cognitive impairment with a BIMS score of 5 out of 15. Despite these conditions, R5's medical record lacked a care plan addressing nutrition or hydration needs, which are critical given the resident's medical history and recent significant weight loss of 12.4 pounds (15%) since admission. The deficiency was further highlighted when R5 was hospitalized to optimize hydration and stabilize electrolytes after being diagnosed with thyrotoxicosis, UTI, candiduria, hypernatremia, and hypercalcemia. Interviews with R5's guardian and facility staff, including an LPN and the DON, confirmed the absence of a nutrition care plan. The staff attempted to address R5's nutritional needs by trying nutritional shakes and requesting the guardian to bring favorite foods from home, but these efforts were not part of a formalized care plan, as verified by the DON.
Failure to Provide Routine Nail Care
Penalty
Summary
The facility failed to provide routine nail care for a resident, identified as R28, who was unable to perform activities of daily living independently. R28 had multiple diagnoses, including renal failure, arthritis, and hypertension, and was assessed to have moderate cognitive impairment. Despite requiring assistance for all care, R28 reported concerns about the length and condition of their fingernails and toenails, which were causing discomfort. Upon observation, the surveyor noted that R28's fingernails were excessively long, split, and jagged, while the toenails were thick, yellow, and curling, indicating a lack of proper nail care. Interviews with facility staff revealed inconsistencies in the provision of nail care. Certified Nurse Assistants (CNAs) were responsible for providing nail care during weekly showers, except for diabetic residents, who required a nurse's assistance. However, CNA-G admitted to never having provided nail care during their four-month tenure at the facility. The Director of Nursing confirmed that nail care should be part of the routine care provided on shower days. The Registered Nurse (RN) verified the lack of proper nail care for R28 and subsequently provided the necessary care after the surveyor's observation.
Inadequate Catheter Care for Resident
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with an indwelling catheter, as observed by surveyors. The resident, who had a history of diabetes, chronic kidney disease, heart failure, and urinary tract infection, was admitted with moderate cognitive impairment and had a Foley catheter placed for comfort. On two separate occasions, the surveyor observed the resident's catheter drainage bag and tubing in contact with the floor, which is against proper catheter care practices. The facility's Catheter Care policy did not address the correct positioning or placement of catheter tubing or drainage bags. Interviews with a CNA, an LPN, and the Director of Nursing confirmed that catheter bags and tubing should not touch the floor. Despite this understanding, the deficiency was noted when the catheter bag and tubing were observed dragging on the floor, indicating a lapse in adherence to proper catheter care protocols.
Failure to Provide Prescribed Nutritional Support
Penalty
Summary
The facility failed to provide necessary nutritional treatment and services for a resident, identified as R33, who was at risk for nutritional status change due to low body weight and weight decline. R33 was prescribed large portions for meals and a nutritional supplement three times daily for weight management. However, during a lunch service, the kitchen staff did not ensure R33 received the prescribed large portions. Additionally, after R33 returned from a hospital stay, the nutritional supplement was not provided for 11 days, despite being previously ordered by the physician due to significant weight loss. R33's medical records indicated a history of weight loss, with a notable decline from 130.6 pounds to 122.2 pounds over a short period, which was a 6.4% weight loss in less than 30 days. The resident had a history of weighing 165 pounds approximately a year ago and expressed a desire to gain weight. Despite the resident's stable weight since returning from the hospital, the failure to re-initiate the nutritional supplement and provide large meal portions as ordered contributed to the deficiency. Interviews with facility staff, including a Registered Dietician and the President of Success, revealed a lack of policies for nutrition or re-admission orders. The staff acknowledged the oversight in not re-initiating the nutritional supplement upon the resident's return from the hospital and the failure to provide large portions during meal service. The facility's practice of treating residents as new admissions after being out for more than three days was noted, but the necessary review and comparison of orders were not adequately conducted in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 52 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Door County Memorial Hospital Snf | 1.1 mi | ★★★★★ | 3 | 0 |
| Amethyst Health Of Algoma | 16.5 mi | ★★★★★ | 2 | 1 |
| Luther Home | 20.3 mi | ★★★★★ | 16 | 0 |
| Menominee Health Services | 23 mi | ★★★★★ | 3 | 0 |
| Rennes Health And Rehab Center-east | 23.5 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Sturgeon Bay Health Services.
100% money-back within 48 hours.
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.