St Elizabeth Nursing Home
109 S. Atwood Ave., Janesville, WI 53545 · Rock County · 43 certified beds · avg 40 residents/day · certified since Feb 1, 1998
Part of chain: ILLUMINUS (5 facilities, chain avg rating 2.0★)
2/5
Health inspection rating (on-site)
2
Serious findings on record
$31,171
Fines, last 3 years
3.27
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Oct 17, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 15, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 8, 2025 · F-0881 · triggered by a complaint
The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective.
Why it matters: Overused antibiotics cause side effects and breed resistant infections that are much harder to treat.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 22, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (59)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 28, 2026 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Apr 28, 2026 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Apr 28, 2026 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Apr 28, 2026 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Apr 28, 2026 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Apr 28, 2026 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Apr 28, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 28, 2026 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Feb 3, 2026 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Feb 13, 2025 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 13, 2025 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Feb 13, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Feb 13, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Feb 13, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Feb 13, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Feb 13, 2025 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Feb 13, 2025 | D · Potential for harm, one-off | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
| Jan 8, 2025 | ▲ G · Actual harm, one-off | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. · from a complaint |
| Jan 8, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Jan 8, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Jan 8, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Oct 17, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Oct 17, 2024 | F · Potential for harm, facility-wide | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Oct 17, 2024 | F · Potential for harm, facility-wide | The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. · from a complaint |
| Oct 17, 2024 | E · Potential for harm, repeated | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. · from a complaint |
| Oct 17, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Oct 17, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Oct 17, 2024 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. · from a complaint |
| Oct 17, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Jul 17, 2024 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint |
| Jul 17, 2024 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Jul 17, 2024 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. · from a complaint |
| Jul 17, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Jul 17, 2024 | D · Potential for harm, one-off | The facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. · from a complaint |
| Jul 17, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jul 17, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jun 21, 2024 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Jun 21, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jun 21, 2024 | D · Potential for harm, one-off | The facility did not properly prepare residents for a safe transfer or discharge. Before a resident leaves, the facility must get them ready and make sure the move is safe and orderly. · from a complaint |
| Jan 30, 2024 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jan 30, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Jan 30, 2024 | E · Potential for harm, repeated | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. · from a complaint |
| Jan 30, 2024 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jan 30, 2024 | D · Potential for harm, one-off | The facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately. · from a complaint |
| Jan 30, 2024 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Jan 30, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| Jan 30, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Jan 30, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 30, 2024 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint |
| Jan 30, 2024 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · from a complaint |
| Jan 30, 2024 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. · from a complaint |
| Jan 30, 2024 | D · Potential for harm, one-off | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. · from a complaint |
| Jan 30, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. · from a complaint |
| Jan 30, 2024 | C · Minimal risk, facility-wide | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. |
| Nov 9, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Aug 15, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Aug 15, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Aug 15, 2023 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. · from a complaint |
| Aug 15, 2023 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (8 → 8).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 5 | 0 | D |
| 2024 | 33 | 1 | J ▲ |
| 2025 | 12 | 1 | G ▲ |
| 2026 | 9 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $31,171.
| Date | Type | Amount / length |
|---|---|---|
| Jan 8, 2025 | Fine | $8,824 |
| Oct 17, 2024 | Fine | $22,347 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Wisconsin avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.27 | 4.29 | 3.95 | bottom 14% in Wisconsin; bottom 25% in the U.S. |
| Registered Nurse hours | 0.58 | 1.01 | 0.69 | bottom 10% in Wisconsin; bottom 50% in the U.S. |
| Weekend total nurse staffing | 2.81 | 3.84 | 3.50 | bottom 11% in Wisconsin; bottom 21% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.40 | 0.68 | 0.48 | bottom 16% in Wisconsin; top 48% in the U.S. |
| Total nursing staff turnover (%) | 57.8 | 46.9 | 45.8 | bottom 23% in Wisconsin; bottom 20% in the U.S. |
| RN turnover (%) | 50.0 | 39.7 | 42.9 | bottom 36% in Wisconsin; bottom 39% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.96, RN 0.53, weekend 2.54. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: 1/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Dettman, Scott | Individual | Corporate Director | NOT APPLICABLE | 09/01/2020 |
| Fischer, Todd | Individual | Corporate Director | NOT APPLICABLE | 04/30/2018 |
| Heroux, Steven | Individual | Corporate Director | NOT APPLICABLE | 08/01/2024 |
| Illuminus INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/30/2018 |
| Illuminus INC | Organization | ADP of the SNF | NOT APPLICABLE | 10/17/2025 |
| Kohlhoff, Kevin | Individual | Corporate Director | NOT APPLICABLE | 09/01/2023 |
| Konkol, Dennis | Individual | Corporate Director | NOT APPLICABLE | 10/01/2024 |
| Marks, Julie | Individual | Corporate Officer | NOT APPLICABLE | 06/09/2025 |
| Marks, Julie | Individual | ADP of the SNF | NOT APPLICABLE | 06/09/2025 |
| Mauthe, Matthew | Individual | Corporate Officer | NOT APPLICABLE | 04/30/2018 |
| Mauthe, Matthew | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/30/2018 |
| Mauthe, Matthew | Individual | ADP of the SNF | NOT APPLICABLE | 04/30/2018 |
| Meidenbauer, Robert | Individual | Corporate Director | NOT APPLICABLE | 09/01/2019 |
| Sidhu, Sarfraz | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/06/2021 |
| Sidhu, Sarfraz | Individual | ADP of the SNF | NOT APPLICABLE | 04/06/2021 |
| Van Der Linden, Katie | Individual | Corporate Director | NOT APPLICABLE | 05/01/2021 |
| Wagner, Lynne | Individual | Corporate Director | NOT APPLICABLE | 10/01/2024 |
| Wilson, Deanna | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/28/2024 |
| Wilson, Deanna | Individual | ADP of the SNF | NOT APPLICABLE | 04/22/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Who oversees antibiotic use here, and how do you decide when an antibiotic is really needed?"
- "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
- "How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Mercy Manor Transition Center | 0.8 mi | Janesville, WI | ★★★★★ | 4/5 | |
| Rock Haven | 1.6 mi | Janesville, WI | ★★★★☆ | 3/5 | |
| Oak Park Place of Janesville | 1.6 mi | Janesville, WI | ★★☆☆☆ | 2/5 | |
| Cedar Crest Health Center | 2.7 mi | Janesville, WI | ★★★★★ | 5/5 | |
| Beloit Health and Rehabilitation Center | 9.4 mi | Beloit, WI | ★★☆☆☆ | 2/5 | |
| Autumn Lake Healthcare at Beloit | 10.5 mi | Beloit, WI | ★★★☆☆ | 3/5 | |
| Edgerton Care Center, INC | 11.2 mi | Edgerton, WI | ★☆☆☆☆ | 1/5 | abuse |
| Alden Meadow Park HCC | 11.2 mi | Clinton, WI | ★★★☆☆ | 3/5 | |
| Fair Oaks Rehab & Healthcare | 14.2 mi | South Beloit, IL | ★☆☆☆☆ | 2/5 | abuse |
| Evansville Manor Nursing and Rehab, LLC | 16.5 mi | Evansville, WI | ★☆☆☆☆ | 1/5 | abuseSFF |
| Skaalen Nursing and Rehabilitation Center | 19.0 mi | Stoughton, WI | ★★★★★ | 5/5 | |
| Complete Care at Nazareth LLC | 19.6 mi | Stoughton, WI | ★★☆☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 525639.