St Elizabeth Nursing Home
109 S Atwood Avenue · Janesville, WI · 53545 · 6087526709
43 certified beds Non profit - Corporation Chain: Illuminus
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
2 immediate-jeopardy citations in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 2 of 5 Staffing: 1 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | 3.13 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.53 | 0.55–0.75 |
| Weekend hours / resident-day | 2.79 | ≈ weekday level |
| Nursing turnover / year | 58% | median 45% |
| Fines (3-yr window) | 2 · $31,171 |
Inspection citations (63 in the current record)
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Potential for harm · D April 28, 2026 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has no plan of correction · Quality of Life and Care
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Potential for harm · E April 28, 2026 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Deficient, Provider has no plan of correction · Nursing and Physician Services
-
Potential for harm · E February 3, 2026 · found via complaint
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 February 24, 2026 · Resident Rights
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Potential for harm · D February 13, 2025
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 March 14, 2025 · Resident Rights
-
Potential for harm · D February 13, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected March 14, 2025 · Resident Assessment and Care Planning
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Potential for harm · D February 13, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected March 14, 2025 · Quality of Life and Care
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Potential for harm · D February 13, 2025
Provide safe, appropriate pain management for a resident who requires such services.
Corrected March 14, 2025 · Quality of Life and Care
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Potential for harm · D February 13, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected March 14, 2025 · Pharmacy Service
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Potential for harm · D February 13, 2025
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 March 14, 2025 · Pharmacy Service
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Potential for harm · F February 13, 2025
Provide and implement an infection prevention and control program.
Corrected March 14, 2025 · Infection Control
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Potential for harm · D February 13, 2025
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 March 14, 2025 · Infection Control
-
Actual harm · G January 8, 2025 · found via complaint
Implement a program that monitors antibiotic use.
Corrected January 22, 2025 · Infection Control
-
Potential for harm · D January 8, 2025 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected January 22, 2025 · Resident Rights
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Potential for harm · D January 8, 2025 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected January 22, 2025 · Resident Assessment and Care Planning
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Potential for harm · D January 8, 2025 · found via complaint
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 January 22, 2025 · Pharmacy Service
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Immediate jeopardy · J October 17, 2024 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected November 15, 2024 · Quality of Life and Care
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Potential for harm · D October 17, 2024 · found via complaint
Respond appropriately to all alleged violations.
Corrected November 15, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E October 17, 2024 · found via complaint
Provide appropriate foot care.
Corrected November 15, 2024 · Quality of Life and Care
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Potential for harm · D October 17, 2024 · found via complaint
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 November 15, 2024 · Quality of Life and Care
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Potential for harm · F October 17, 2024 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected November 15, 2024 · Nursing and Physician Services
-
Potential for harm · D October 17, 2024 · found via complaint
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 November 15, 2024 · Pharmacy Service
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Potential for harm · D October 17, 2024 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected November 15, 2024 · Pharmacy Service
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Potential for harm · F October 17, 2024 · found via complaint
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 November 15, 2024 · Administration
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Potential for harm · D July 17, 2024 · found via complaint
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected August 16, 2024 · Resident Rights
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Potential for harm · D July 17, 2024 · found via complaint
Respond appropriately to all alleged violations.
Corrected August 16, 2024 · Freedom from Abuse, Neglect, and Exploitation
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| January 8, 2025 | Fine | $8,824 |
| October 17, 2024 | Fine | $22,347 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 525639 · certified since February 1, 1998. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.