Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Door County Memorial Hospital SNF
Sturgeon Bay, WI · 32 certified beds · Last Life Safety survey April 28, 2026
CMS Certification Number 525377 · first certified October 1984
Ownership
Independently operated (no chain recorded by CMS) · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within WI
14 citations — more than 35% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 2 citations; the earlier surveys in the window averaged 6. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens June 2027 — about 8 months from now. This facility’s last Life Safety survey was April 2026. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 14 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 14 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| January 4, 2024 | 9 |
| February 19, 2025 | 3 |
| April 28, 2026 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-02-19 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2025-02-19 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2024-01-04 |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | 1 | 2024-01-04 |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | 1 | 2025-02-19 |
| K-0753 | Have restrictions on the use of highly flammable decorations. | 1 | 2024-01-04 |
| K-0281 | Install proper backup exit lighting. | 1 | 2024-01-04 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2024-01-04 |
What the citations cover
- Smoke Deficiencies 7
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Egress Deficiencies 2
- Miscellaneous Deficiencies 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 7 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Egress Deficiencies | 2 |
| Miscellaneous Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
April 28, 2026 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 22, 2026) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (May 8, 2026) |
February 19, 2025 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (March 11, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 26, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 6, 2025) |
January 4, 2024 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0200 | Meet other general requirements. | Deficient, Provider has date of correction (January 8, 2024) |
| K-0281 | Install proper backup exit lighting. | Waiver has been granted (June 11, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (February 16, 2024) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (January 8, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (January 31, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (January 8, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (January 31, 2024) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (January 8, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Waiver has been granted (June 11, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.