Cycle 1
Health 2025-02-13 · Fire 2025-02-13
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
St Elizabeth Nursing Home
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
Facility snapshot
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
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.64
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.41
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.22
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.05
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
2.87
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.55
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
3.29
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
68%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,672
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
1.92
Composite VBP score used to determine payment impact.
Payment multiplier
0.9804
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.62% · Performance 21.94% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.34% · Performance 7.95% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 46.67% · Performance 74.42% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.77
Baseline 3.51 hours · Performance 3.30 hours · Measure score 0.77 · Achievement 0.77 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.24% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 71 · Observed rate 8.45% · Lower 95% interval 7.18% |
| Discharge to community | 43.48% |
50.57%
7.1 pts worse
|
No Different than the National Rate · Eligible stays 73 · Observed rate 35.62% · Lower 95% interval 30.79% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.56% |
95.27%
2.3 pts better
|
Numerator 40 · Denominator 41 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 41 |
| Discharge self-care score | 26.67% |
53.69%
27 pts worse
|
Numerator 8 · Denominator 30 |
| Discharge mobility score | 23.33% |
50.94%
27.6 pts worse
|
Numerator 7 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 4.88% |
2.29%
2.6 pts worse
|
Numerator 2 · Denominator 41 · Adjusted rate 4.62% |
| Healthcare-associated infections requiring hospitalization | 7.95% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 10% · Lower 95% interval 4.6% |
| Staff COVID-19 vaccination coverage | 4.55% |
8.2%
3.6 pts worse
|
Numerator 2 · Denominator 44 |
| Staff flu vaccination coverage | 67.16% |
42%
25.2 pts better
|
Numerator 45 · Denominator 67 |
| Discharge function score | 30% |
56.45%
26.5 pts worse
|
Numerator 9 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| 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 · Q1 88.5% · Q2 88.9% · Q3 92.6% · Q4 90.0% · 4Q avg 90.0% |
| 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 · 4Q avg 89.7% |
| 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 · Q1 3.8% · Q2 7.4% · Q3 3.7% · Q4 3.3% · 4Q avg 4.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · Q1 0.0% · Q2 0.0% · Q3 14.3% · Q4 0.0% · 4Q avg 3.4% |
| 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 · Q1 18.2% · Q2 23.8% · Q3 18.2% · Q4 20.0% · 4Q avg 20.0% |
| 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 · 4Q avg 18.8% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · 4Q avg 31.0% · Used in QM five-star |
| 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 · Q4 28.6% · 4Q avg 17.1% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · Q1 7.7% · Q2 3.8% · Q3 0.0% · Q4 6.9% · 4Q avg 4.7% · Used in QM five-star |
| 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 · Q1 22.2% · Q2 36.7% · Q3 30.6% · Q4 22.3% · 4Q avg 27.7% |
| 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 · Q1 2.7% · Q2 3.1% · Q3 3.1% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| 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 · Q1 65.6% · Q2 55.6% · Q3 70.2% · Q4 57.9% · 4Q avg 62.2% |
| 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 · Adjusted 48.9% · Observed 53.6% · Expected 12.2% · Used in QM five-star |
| 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 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · 4Q avg 59.5% |
| 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 · Adjusted 20.6% · Observed 21.4% · Expected 24.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-30 · Fire 2024-01-30
37 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-11-07 · Fire 2022-11-07
15 health 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 citations
F · Potential for more than minimal harm
2025-02-13
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-03-14
F · Potential for more than minimal harm
2025-02-13
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-03-10
F · Potential for more than minimal harm
2025-02-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-13
F · Potential for more than minimal harm
2025-02-13
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
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
F · Potential for more than minimal harm
2025-02-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-14
E · Potential for more than minimal harm
2025-02-13
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2025-03-14
E · Potential for more than minimal harm
2025-02-13
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-03-04
E · Potential for more than minimal harm
2025-02-13
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-02-26
E · Potential for more than minimal harm
2025-02-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-02-13
K741 · Miscellaneous Deficiencies
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
D · Potential for more than minimal harm
2025-02-13
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-02-26
C · Minimal harm
2025-02-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-28
F · Potential for more than minimal harm
2024-01-30
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-04-01
E · Potential for more than minimal harm
2024-01-30
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-03-01
E · Potential for more than minimal harm
2024-01-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-04
E · Potential for more than minimal harm
2024-01-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-01
E · Potential for more than minimal harm
2024-01-30
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-05-29
E · Potential for more than minimal harm
2024-01-30
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-01-30
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-03-01
E · Potential for more than minimal harm
2024-01-30
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-01-30
K222 · Egress Deficiencies
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
D · Potential for more than minimal harm
2024-01-30
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-03-01
F · Potential for more than minimal harm
2022-11-07
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-12-01
F · Potential for more than minimal harm
2022-11-07
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-12-01
F · Potential for more than minimal harm
2022-11-07
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2022-12-01
F · Potential for more than minimal harm
2022-11-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-01
F · Potential for more than minimal harm
2022-11-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-01
F · Potential for more than minimal harm
2022-11-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-12-01
F · Potential for more than minimal harm
2022-11-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-01
E · Potential for more than minimal harm
2022-11-07
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-12-01
D · Potential for more than minimal harm
2022-11-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-01
D · Potential for more than minimal harm
2022-11-07
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2022-12-01
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-02-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-02-13
F578 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2025-02-13
F656 · Resident Assessment and Care Planning Deficiencies
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
D · Potential for more than minimal harm
2025-02-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-02-13
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-02-13
F755 · Pharmacy Service Deficiencies
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
D · Potential for more than minimal harm
2025-02-13
F758 · Pharmacy Service Deficiencies
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
D · Potential for more than minimal harm
2025-02-13
F887 · Infection Control Deficiencies
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
G · Actual harm
2025-01-08
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-01-22
D · Potential for more than minimal harm
2025-01-08
F580 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2025-01-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-22
D · Potential for more than minimal harm
2025-01-08
F761 · Pharmacy Service Deficiencies
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
J · Immediate jeopardy
2024-10-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-10-17
F725 · Nursing and Physician Services Deficiencies
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
F · Potential for more than minimal harm
2024-10-17
F838 · Administration Deficiencies
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
E · Potential for more than minimal harm
2024-10-17
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-17
F690 · Quality of Life and Care Deficiencies
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
D · Potential for more than minimal harm
2024-10-17
F758 · Pharmacy Service Deficiencies
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
D · Potential for more than minimal harm
2024-10-17
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-07-17
F727 · Nursing and Physician Services Deficiencies
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
E · Potential for more than minimal harm
2024-07-17
F657 · Resident Assessment and Care Planning Deficiencies
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
D · Potential for more than minimal harm
2024-07-17
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-17
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-17
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-06-21
F580 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2024-06-21
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-21
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-07-18
F · Potential for more than minimal harm
2024-01-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-01
E · Potential for more than minimal harm
2024-01-30
F584 · Resident Rights Deficiencies
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
E · Potential for more than minimal harm
2024-01-30
F678 · Quality of Life and Care Deficiencies
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
E · Potential for more than minimal harm
2024-01-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-01-30
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-01-30
F585 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2024-01-30
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-01-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-01-30
F693 · Quality of Life and Care Deficiencies
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
D · Potential for more than minimal harm
2024-01-30
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-01-30
F758 · Pharmacy Service Deficiencies
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
D · Potential for more than minimal harm
2024-01-30
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-01-30
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-03-01
C · Minimal harm
2024-01-30
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-03-01
D · Potential for more than minimal harm
2023-11-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-11
D · Potential for more than minimal harm
2023-08-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-15
F623 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2023-08-15
F842 · Resident Assessment and Care Planning Deficiencies
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
J · Immediate jeopardy
2022-11-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-01-19
F · Potential for more than minimal harm
2022-11-07
F812 · Nutrition and Dietary Deficiencies
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
D · Potential for more than minimal harm
2022-11-07
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-12-01
D · Potential for more than minimal harm
2022-11-07
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-12-01
D · Potential for more than minimal harm
2022-11-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-12-01
D · Potential for more than minimal harm
2022-11-07
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-12-01
D · Potential for more than minimal harm
2022-11-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-12-01
D · Potential for more than minimal harm
2022-11-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-01
D · Potential for more than minimal harm
2022-11-07
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-12-01
D · Potential for more than minimal harm
2022-11-07
F887 · Infection Control Deficiencies
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
What sits behind the stars
$8,824
2025-01-08
Fine
Fine · fine $8,824
Fine
$22,347
2024-10-17
Fine
Fine · fine $22,347
Fine
Ownership
Dettman, Scott
Corporate Director · Individual
Fischer, Todd
Corporate Director · Individual
Heroux, Steven
Corporate Director · Individual
Illuminus Inc
Operational/Managerial Control · Organization
Kohlhoff, Kevin
Corporate Director · Individual
Konkol, Dennis
Corporate Director · Individual
Marks, Julie
Corporate Officer · Individual
Mauthe, Matthew
Operational/Managerial Control · Individual
Mauthe, Matthew
Corporate Officer · Individual
Meidenbauer, Robert
Corporate Director · Individual
Sidhu, Sarfraz
Operational/Managerial Control · Individual
Van Der Linden, Katie
Corporate Director · Individual
Wagner, Lynne
Corporate Director · Individual
Wilson, Deanna
Operational/Managerial Control · Individual
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#3
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