Door County Memorial Hospital Snf

Inspection findings

1. Apr 28, 2026 Health · 3 findings
   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jun 8, 2026 · CMS health inspection

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Jun 22, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0916 Gas, Vacuum, and Electrical Systems Deficiencies

     Have a battery powered remote alarm panel in a location accessible by operating personnel.

     Corrected May 8, 2026 · CMS fire safety

2. Jul 2, 2025 Health · 4 findings
   • Not serious Scope/severity D Complaint

     F0580 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.

     Corrected Jul 23, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Jul 27, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Jul 25, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0842 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.

     Corrected Jul 23, 2025 · CMS health inspection

3. Feb 19, 2025 Health · 6 findings
   • Not serious Scope/severity D

     F0580 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.

     Corrected Feb 22, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Mar 12, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Feb 27, 2025 · CMS health inspection

   • Not serious Scope/severity F

     K0346 Smoke Deficiencies

     Follow proper procedures when the fire alarm was out of service for more than 4 hours.

     Corrected Mar 11, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Mar 26, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Mar 6, 2025 · CMS fire safety

4. Jan 4, 2024 Health · 10 findings
   • Not serious Scope/severity E Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Feb 12, 2024 · CMS health inspection

   • Not serious Scope/severity D

     K0200 Egress Deficiencies

     Meet other general requirements.

     Corrected Jan 8, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0281 Egress Deficiencies

     Install proper backup exit lighting.

     Corrected Jun 11, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Feb 16, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0362 Smoke Deficiencies

     Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

     Corrected Jan 8, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Jan 31, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Jan 8, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Jan 31, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0753 Miscellaneous Deficiencies

     Have restrictions on the use of highly flammable decorations.

     Corrected Jan 8, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Jun 11, 2024 · CMS fire safety

Owners and managers (as published by CMS)

• ALBERTS, JAMIE — adp of the snf, NOT APPLICABLE, since 01/01/2021
• ALBERTS, JAMIE — operational/managerial control, NOT APPLICABLE, since 01/01/2021
• ALBERTS, JAMIE — corporate director, NOT APPLICABLE, since 01/01/2021
• ANDREAE, BRADLEY — adp of the snf, NOT APPLICABLE, since 01/01/2024
• ANDREAE, BRADLEY — corporate director, NOT APPLICABLE, since 01/01/2024
• ANDREAE, BRADLEY — operational/managerial control, NOT APPLICABLE, since 01/01/2024
• ANTONIO, MARIA CHONA — adp of the snf, NOT APPLICABLE, since 07/01/2024
• ANTONIO, MARIA CHONA — operational/managerial control, NOT APPLICABLE, since 07/01/2024
• BOHRMAN, NANCY — adp of the snf, NOT APPLICABLE, since 07/01/2024
• BOHRMAN, NANCY — operational/managerial control, NOT APPLICABLE, since 07/01/2024
• COLLISON, EDGAR — adp of the snf, NOT APPLICABLE, since 05/14/2025
• COLLISON, EDGAR — operational/managerial control, NOT APPLICABLE, since 05/14/2025
• COLLISON, EDGAR — corporate director, NOT APPLICABLE, since 05/14/2025
• DAHL, CORWIN — operational/managerial control, NOT APPLICABLE, since 01/01/2021
• DAHL, CORWIN — adp of the snf, NOT APPLICABLE, since 01/01/2021
• DAHL, CORWIN — corporate director, NOT APPLICABLE, since 01/01/2021
• DEMPSTER, DORENE — corporate director, NOT APPLICABLE, since 01/01/2019
• DEMPSTER, DORENE — operational/managerial control, NOT APPLICABLE, since 01/01/2019
• DEMPSTER, DORENE — adp of the snf, NOT APPLICABLE, since 01/01/2019
• ERICKSON, ROBERT — adp of the snf, NOT APPLICABLE, since 05/15/2024
• ERICKSON, ROBERT — operational/managerial control, NOT APPLICABLE, since 05/15/2024
• ERICKSON, ROBERT — corporate director, NOT APPLICABLE, since 05/15/2024
• HELGESON, ERIN — adp of the snf, NOT APPLICABLE, since 01/01/2024
• HELGESON, ERIN — corporate director, NOT APPLICABLE, since 01/01/2024
• HELGESON, ERIN — operational/managerial control, NOT APPLICABLE, since 01/01/2024
• HELM, PAULINE — corporate director, NOT APPLICABLE, since 01/01/2023
• HELM, PAULINE — operational/managerial control, NOT APPLICABLE, since 01/01/2023
• HELM, PAULINE — adp of the snf, NOT APPLICABLE, since 01/01/2023
• JAROSH, JONATHAN — corporate director, NOT APPLICABLE, since 01/01/2024
• JAROSH, JONATHAN — operational/managerial control, NOT APPLICABLE, since 01/01/2024
• JAROSH, JONATHAN — adp of the snf, NOT APPLICABLE, since 01/01/2024
• KITCHENS, JOEL — operational/managerial control, NOT APPLICABLE, since 01/01/2021
• KITCHENS, JOEL — corporate director, NOT APPLICABLE, since 01/01/2021
• KITCHENS, JOEL — adp of the snf, NOT APPLICABLE, since 01/01/2021
• LALUZERNE, ANDREW — operational/managerial control, NOT APPLICABLE, since 10/29/2018
• LALUZERNE, ANDREW — adp of the snf, NOT APPLICABLE, since 10/29/2018
• LALUZERNE, ANDREW — corporate officer, NOT APPLICABLE, since 10/29/2018
• RABAS, JEFFREY — operational/managerial control, NOT APPLICABLE, since 01/01/2022
• RABAS, JEFFREY — corporate director, NOT APPLICABLE, since 01/01/2022
• RABAS, JEFFREY — adp of the snf, NOT APPLICABLE, since 01/01/2022
• REBHAN, JOSEPH — operational/managerial control, NOT APPLICABLE, since 01/01/2026
• REBHAN, JOSEPH — adp of the snf, NOT APPLICABLE, since 01/01/2026
• REBHAN, JOSEPH — corporate director, NOT APPLICABLE, since 01/01/2026
• RICHMOND, ANDREW — operational/managerial control, NOT APPLICABLE, since 10/01/2017
• RICHMOND, ANDREW — corporate director, NOT APPLICABLE, since 10/01/2017
• RICHMOND, ANDREW — adp of the snf, NOT APPLICABLE, since 10/01/2017
• ST JEAN, MICHAEL — adp of the snf, NOT APPLICABLE, since 01/01/2025
• ST JEAN, MICHAEL — corporate director, NOT APPLICABLE, since 01/01/2025
• ST JEAN, MICHAEL — operational/managerial control, NOT APPLICABLE, since 01/01/2025
• STEPHENS, BRIAN — corporate officer, NOT APPLICABLE, since 01/06/2019
• STEPHENS, BRIAN — operational/managerial control, NOT APPLICABLE, since 01/06/2019
• STEPHENS, BRIAN — adp of the snf, NOT APPLICABLE, since 01/06/2019
• STERNARD, TAMMY — adp of the snf, NOT APPLICABLE, since 01/01/2025
• STERNARD, TAMMY — operational/managerial control, NOT APPLICABLE, since 01/01/2025
• STERNARD, TAMMY — corporate director, NOT APPLICABLE, since 01/01/2025
• URBAN, CAROLINE — adp of the snf, NOT APPLICABLE, since 07/01/2024
• URBAN, CAROLINE — operational/managerial control, NOT APPLICABLE, since 07/01/2024
• VICKMAN, PATRICIA — corporate director, NOT APPLICABLE, since 10/01/2017
• VICKMAN, PATRICIA — adp of the snf, NOT APPLICABLE, since 10/01/2017
• VICKMAN, PATRICIA — operational/managerial control, NOT APPLICABLE, since 10/01/2017
• ZIEGELBAUER, MARTHA — corporate director, NOT APPLICABLE, since 01/01/2022
• ZIEGELBAUER, MARTHA — operational/managerial control, NOT APPLICABLE, since 01/01/2022
• ZIEGELBAUER, MARTHA — adp of the snf, NOT APPLICABLE, since 01/01/2022
• ST VINCENT HOSPITAL-HOSPITAL SISTERS-THIRD ORDER OF ST FRANCIS — operational/managerial control, NOT APPLICABLE, since 10/28/2016
• ST VINCENT HOSPITAL-HOSPITAL SISTERS-THIRD ORDER OF ST FRANCIS — adp of the snf, NOT APPLICABLE, since 02/14/2025