Starfile / Wisconsin

ST ELIZABETH NURSING HOME

109 S ATWOOD AVENUE, JANESVILLE, WI 53545 · CCN 525639

Inspection history vs Wisconsin & national averages

Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.

Cycle 1 deficiencies by category

Staffing (hours per resident per day)

Fines & penalties

Total fines

$31,171

Number of fines

2

Number of penalties

2

Payment denials

0

Inspection citations (60)2 immediate jeopardy1 actual harm

1. DF0578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.2025-02-13 · Health · corrected 2025-03-14

   Potential for more than minimal harm

2. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2025-02-13 · Health · corrected 2025-03-14

   Potential for more than minimal harm

3. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-02-13 · Health · corrected 2025-03-14

   Potential for more than minimal harm

4. DF0697Provide safe, appropriate pain management for a resident who requires such services.2025-02-13 · Health · corrected 2025-03-14

   Potential for more than minimal harm

5. DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2025-02-13 · Health · corrected 2025-03-14

   Potential for more than minimal harm

6. DF0758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.2025-02-13 · Health · corrected 2025-03-14

   Potential for more than minimal harm

7. FF0880Provide and implement an infection prevention and control program.2025-02-13 · Health · corrected 2025-03-14

   Potential for more than minimal harm

8. DF0887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.2025-02-13 · Health · corrected 2025-03-14

   Potential for more than minimal harm

9. DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2025-01-08 · Health · corrected 2025-01-22

   Potential for more than minimal harm

10. DF0658Ensure services provided by the nursing facility meet professional standards of quality.2025-01-08 · Health · corrected 2025-01-22

    Potential for more than minimal harm

11. DF0761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.2025-01-08 · Health · corrected 2025-01-22

    Potential for more than minimal harm

12. GF0881Implement a program that monitors antibiotic use.2025-01-08 · Health · corrected 2025-01-22

    Actual harm

13. DF0610Respond appropriately to all alleged violations.2024-10-17 · Health · corrected 2024-11-15

    Potential for more than minimal harm

14. JF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-10-17 · Health · corrected 2024-11-15

    Immediate jeopardy

15. EF0687Provide appropriate foot care.2024-10-17 · Health · corrected 2024-11-15

    Potential for more than minimal harm

16. DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2024-10-17 · Health · corrected 2024-11-15

    Potential for more than minimal harm

17. FF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2024-10-17 · Health · corrected 2024-11-15

    Potential for more than minimal harm

18. DF0758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.2024-10-17 · Health · corrected 2024-11-15

    Potential for more than minimal harm

19. DF0760Ensure that residents are free from significant medication errors.2024-10-17 · Health · corrected 2024-11-15

    Potential for more than minimal harm

20. FF0838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.2024-10-17 · Health · corrected 2024-11-15

    Potential for more than minimal harm

21. DF0554Allow residents to self-administer drugs if determined clinically appropriate.2024-07-17 · Health · corrected 2024-08-16

    Potential for more than minimal harm

22. DF0610Respond appropriately to all alleged violations.2024-07-17 · Health · corrected 2024-08-16

    Potential for more than minimal harm

23. EF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2024-07-17 · Health · corrected 2024-08-16

    Potential for more than minimal harm

24. DF0660Plan the resident's discharge to meet the resident's goals and needs.2024-07-17 · Health · corrected 2024-08-16

    Potential for more than minimal harm

25. DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2024-07-17 · Health · corrected 2024-08-16

    Potential for more than minimal harm

26. FF0727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.2024-07-17 · Health · corrected 2024-08-16

    Potential for more than minimal harm

27. DF0880Provide and implement an infection prevention and control program.2024-07-17 · Health · corrected 2024-08-16

    Potential for more than minimal harm

28. DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2024-06-21 · Health · corrected 2024-07-18

    Potential for more than minimal harm

29. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2024-06-21 · Health · corrected 2024-07-18

    Potential for more than minimal harm

30. DF0624Prepare residents for a safe transfer or discharge from the nursing home.2024-06-21 · Health · corrected 2024-07-18

    Potential for more than minimal harm

31. DF0576Ensure residents have reasonable access to and privacy in their use of communication methods.2024-01-30 · Health · corrected 2024-03-01

    Potential for more than minimal harm

32. EF0584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.2024-01-30 · Health · corrected 2024-03-01

    Potential for more than minimal harm

33. DF0585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.2024-01-30 · Health · corrected 2024-03-01

    Potential for more than minimal harm

34. DF0607Develop and implement policies and procedures to prevent abuse, neglect, and theft.2024-01-30 · Health · corrected 2024-02-23

    Potential for more than minimal harm

35. EF0678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.2024-01-30 · Health · corrected 2024-01-31

    Potential for more than minimal harm

36. EF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-01-30 · Health · corrected 2024-03-01

    Potential for more than minimal harm

37. DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2024-01-30 · Health · corrected 2024-03-01

    Potential for more than minimal harm

38. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-01-30 · Health · corrected 2024-03-01

    Potential for more than minimal harm

39. DF0693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.2024-01-30 · Health · corrected 2024-03-01

    Potential for more than minimal harm

40. DF0757Ensure each resident’s drug regimen must be free from unnecessary drugs.2024-01-30 · Health · corrected 2024-03-01

    Potential for more than minimal harm

41. DF0758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.2024-01-30 · Health · corrected 2024-03-01

    Potential for more than minimal harm

42. CF0868Have the Quality Assessment and Assurance group have the required members and meet at least quarterly2024-01-30 · Health · corrected 2024-03-01

    Potential for minimal harm

43. FF0880Provide and implement an infection prevention and control program.2024-01-30 · Health · corrected 2024-03-01

    Potential for more than minimal harm

44. DF0881Implement a program that monitors antibiotic use.2024-01-30 · Health · corrected 2024-03-01

    Potential for more than minimal harm

45. DF0883Develop and implement policies and procedures for flu and pneumonia vaccinations.2024-01-30 · Health · corrected 2024-03-01

    Potential for more than minimal harm

46. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2023-11-09 · Health · corrected 2023-12-11

    Potential for more than minimal harm

47. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2023-08-15 · Health · corrected 2023-09-15

    Potential for more than minimal harm

48. DF0610Respond appropriately to all alleged violations.2023-08-15 · Health · corrected 2023-09-15

    Potential for more than minimal harm

49. DF0623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.2023-08-15 · Health · corrected 2023-09-15

    Potential for more than minimal harm

50. DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2023-08-15 · Health · corrected 2023-09-15

    Potential for more than minimal harm

51. DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2022-11-07 · Health · corrected 2022-12-01

    Potential for more than minimal harm

52. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2022-11-07 · Health · corrected 2022-12-01

    Potential for more than minimal harm

53. DF0610Respond appropriately to all alleged violations.2022-11-07 · Health · corrected 2022-12-01

    Potential for more than minimal harm

54. DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2022-11-07 · Health · corrected 2022-12-01

    Potential for more than minimal harm

55. DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2022-11-07 · Health · corrected 2022-12-01

    Potential for more than minimal harm

56. JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2022-11-07 · Health · corrected 2023-01-19

    Immediate jeopardy

57. FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2022-11-07 · Health · corrected 2022-12-01

    Potential for more than minimal harm

58. DF0880Provide and implement an infection prevention and control program.2022-11-07 · Health · corrected 2022-12-01

    Potential for more than minimal harm

59. DF0883Develop and implement policies and procedures for flu and pneumonia vaccinations.2022-11-07 · Health · corrected 2022-12-01

    Potential for more than minimal harm

60. DF0887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.2022-11-07 · Health · corrected 2022-12-01

    Potential for more than minimal harm

Ownership

Other facilities in JANESVILLE

Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.