8 health deficiencies
Top issue: Infection Control (2 deficiencies)
12 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Janesville, WI
1-star overall rating with 2-star inspections with $31,171 in total fines with 8 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
109 S Atwood Avenue, Janesville, WI
(608) 752-6709
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Beds
43
Certified beds
Average residents
38
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1998-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.64
Registered nurse staffing
LPN hours / resident day
0.41
Licensed practical nurse staffing
Aide hours / resident day
2.16
Nurse aide staffing
Weekend hours
2.87
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
68%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.0% |
95.7%
5.7 pts worse
|
93.4%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.7% |
95.0%
5.3 pts worse
|
95.5%
5.8 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
3.2%
1.3 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.0%
5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 3.4% |
4.9%
1.5 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.0% |
16.6%
3.4 pts worse
|
19.6%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 18.8% |
16.7%
2.1 pts worse
|
16.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 31.0% |
21.1%
9.9 pts worse
|
16.3%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.1% |
17.3%
0.2 pts better
|
14.9%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 4.7% |
3.0%
1.7 pts worse
|
1.7%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.7% |
25.5%
2.2 pts worse
|
19.8%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
5.5%
3.4 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 62.2% |
86.8%
24.6 pts worse
|
81.7%
19.5 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 48.9% |
15.0%
33.9 pts worse
|
12.0%
36.9 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 59.5% |
82.2%
22.7 pts worse
|
79.7%
20.2 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.6% |
22.7%
2.1 pts better
|
23.9%
3.3 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Infection Control (2 deficiencies)
12 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Top issue: Quality of Life and Care (9 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-03-14
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-03-10
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-13
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-03-18
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-14
Fire Safety
Construct fire resistant interior walls.
Corrected 2025-03-14
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-03-04
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-02-26
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-26
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-03-10
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-02-26
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-28
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-04-01
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-03-01
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-04
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-01
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-05-29
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-05-10
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-03-01
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-03-08
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-03-03
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-03-01
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-12-01
Fire Safety
Install proper backup exit lighting.
Corrected 2022-12-01
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2022-12-01
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-01
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-01
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-12-01
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-01
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-12-01
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-01
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2022-12-01
Inspection history
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-14
Health
Honor 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.
Corrected 2025-03-14
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-14
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-14
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-03-14
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-14
Health
Implement 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.
Corrected 2025-03-14
Health
Educate 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.
Corrected 2025-03-14
Health
Implement a program that monitors antibiotic use.
Corrected 2025-01-22
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-01-22
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-22
Health
Ensure 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.
Corrected 2025-01-22
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-15
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-11-15
Health
Conduct 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.
Corrected 2024-11-15
Health
Provide appropriate foot care.
Corrected 2024-11-15
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-15
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-11-15
Health
Implement 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.
Corrected 2024-11-15
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-11-15
Health
Have 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.
Corrected 2024-08-16
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-08-16
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-08-16
Health
Respond appropriately to all alleged violations.
Corrected 2024-08-16
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-08-16
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-16
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-16
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-07-18
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-07-18
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-07-18
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-01
Health
Honor 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.
Corrected 2024-03-01
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-01-31
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-01
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-03-01
Health
Honor 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.
Corrected 2024-03-01
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-02-23
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-01
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-01
Health
Ensure 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.
Corrected 2024-03-01
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-03-01
Health
Implement 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.
Corrected 2024-03-01
Health
Implement a program that monitors antibiotic use.
Corrected 2024-03-01
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-03-01
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-03-01
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-11
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-15
Health
Respond appropriately to all alleged violations.
Corrected 2023-09-15
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-09-15
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-09-15
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-01-19
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-12-01
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-12-01
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-12-01
Health
Respond appropriately to all alleged violations.
Corrected 2022-12-01
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-12-01
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-12-01
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-01
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-12-01
Health
Educate 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.
Corrected 2022-12-01
Penalties and ownership
Fine · fine $8,824
Fine
Fine · fine $22,347
Fine
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
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