Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gundersen St Elizabeth's Care Center during CMS and state inspections, most recent first.
Failure to Follow EBP During Resident Transfer. A resident with moderate cognitive impairment, mobility limitations, and an indwelling urinary catheter required EBP during high-contact care. During a transfer to a chair for lunch, the DON entered the room and provided care without applying the required gown and gloves. The facility policy stated that EBP is required for residents with indwelling medical devices during activities such as transferring.
Several residents were provided with bilateral half side rails without evidence that less restrictive alternatives, such as grab bars or positioning devices, were offered, attempted, or documented in their medical records. Staff and residents confirmed that alternatives were not discussed, and consent forms and assessments were incomplete or lacked documentation of alternative options. Facility policy required consideration and documentation of less restrictive interventions prior to side rail use, but this was not followed.
The facility did not consistently monitor or document side effects for residents prescribed psychotropic medications, including antidepressants, antianxiety, and antipsychotics. A resident reported ongoing tiredness linked to her medications, but there was no evidence of systematic side effect tracking. Another resident received PRN lorazepam without a required 14-day limit or documented rationale for continued use. Staff interviews revealed that side effect monitoring was only done after medication changes or by exception, and facility policies lacked clear direction for ongoing monitoring and documentation.
A resident with moderate cognitive impairment and multiple medical conditions used a CPAP device, but direct-care staff had not received formal training or competency validation for its use. The resident's significant other primarily managed the device, and staff relied on informal methods to address issues, with no user manual or structured guidance available. Facility policy required trained staff for CPAP use but did not outline how training would be provided.
A resident with a known history of PTSD and military trauma did not receive a trauma assessment or have PTSD-related triggers and interventions documented in the care plan. Staff were not consistently aware of the resident's PTSD diagnosis, and the facility lacked a process for trauma assessments or a trauma-informed care policy.
The facility did not have a preventative maintenance program for beds and side rails, resulting in several residents having loose side rails and no routine safety inspections. Staff interviews confirmed that maintenance was only performed in response to specific issues, and there was no documentation or policy for regular checks, potentially affecting all residents using beds and side rails.
The facility failed to notify the Ombudsman of a resident's transfer to the hospital. The resident had multiple diagnoses, including CHF, PVD, DM, HLD, and asthma. The administrator confirmed the notification was not sent, and a nurse was unsure of the process. Facility policy required notification to the Ombudsman, but this was not followed.
The facility failed to provide a written notification of the bed hold policy to a resident or their representative during a hospitalization. The resident, with multiple diagnoses, was hospitalized, and the medical record lacked evidence of a written bed hold notification. Interviews confirmed that the facility had not been completing bed holds since before the COVID-19 pandemic, despite policy requirements.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) were followed for one resident who had moderate cognitive impairment, used a walker, required substantial to maximal assistance for toileting, partial to moderate assistance for transferring from bed to chair, and had a urinary catheter related to kidney disease. During an observation, the DON entered the resident’s room to assist with transferring him to a chair for lunch and did not apply the required PPE before providing care. The resident required EBP because of the indwelling urinary catheter, and the facility policy stated that EBP should be used during high-contact care activities such as transferring and requires gown and glove use.
Failure to Offer and Document Alternatives Prior to Bed Rail Use
Penalty
Summary
The facility failed to ensure that alternatives to bed rails, such as small grab bars or positioning devices, were offered, attempted, and documented in the medical record prior to the use of bilateral half side rails for four residents. For each resident observed with side rails, there was no evidence in their medical records that less restrictive alternatives were considered or trialed before the installation of the rails. Documentation, including consent forms and assessments, was incomplete or lacked details regarding the exploration of alternatives. One resident, who had a history of heart failure, obesity, and diabetes, was admitted from the emergency department and assessed as not needing restraints. However, she was observed with bilateral half side rails, and both the resident and staff confirmed that no alternatives were discussed or offered prior to installation. The consent form was signed by the resident but not by staff, and it did not document any alternatives considered. Similar deficiencies were found for other residents, including those with intact cognition and those requiring assistance with mobility, where bed rails were installed without documented evidence of alternative devices being offered or attempted. Interviews with staff, including nursing assistants, the DON, and maintenance personnel, revealed a lack of awareness or process for considering alternatives to side rails. Staff indicated that bed rails were routinely used and often came with the beds, and there was no established practice of evaluating or offering other devices. Facility policy required less restrictive interventions to be considered and documented prior to side rail use, but this was not reflected in the records or staff actions for the residents involved.
Failure to Monitor Psychotropic Medication Side Effects and PRN Use
Penalty
Summary
The facility failed to develop and implement an effective system for ongoing monitoring of side effects in residents prescribed psychotropic medications. Multiple residents were identified as receiving various psychotropic drugs, including antidepressants, antianxiety, and antipsychotic medications, without consistent or documented monitoring for adverse effects. For example, one resident reported persistent tiredness, which was attributed to her medications, but there was no evidence in her medical record or care plans that side effects were being systematically tracked or evaluated. Staff interviews confirmed that side effect monitoring was only performed after medication adjustments or by exception, rather than as an ongoing process. Another resident was prescribed as-needed (PRN) psychotropic medication without adherence to the regulatory requirement that such orders be limited to 14 days unless extended with a documented rationale from the medical provider. The resident's order for PRN lorazepam lacked a scheduled end date and did not include a supporting rationale for continued use, even though the medication was administered multiple times over several months. Interviews with facility staff and the consulting pharmacist revealed a lack of awareness or inconsistent understanding of the requirements for PRN psychotropic medication orders, particularly for hospice residents. Additional residents were found to be receiving psychotropic medications, such as antipsychotics and antidepressants, without documentation of side effect monitoring in their care plans, medication administration records, or progress notes. Staff interviews indicated that monitoring for side effects was not routinely performed unless specifically ordered or if a problem was observed. The facility's policies did not provide clear guidance on monitoring for side effects of non-antipsychotic psychotropic medications or specify where such monitoring should be documented. This lack of systematic monitoring and documentation was observed across multiple residents and confirmed by staff and leadership interviews.
Lack of Staff Training and Competency in CPAP Device Management
Penalty
Summary
The facility failed to ensure that direct-care staff were trained and competent in the daily use of a resident's CPAP (Continuous Positive Airway Pressure) machine, which is necessary for the resident's well-being and safety. The resident, who had moderate cognitive impairment and multiple medical diagnoses including atrial fibrillation and chronic kidney disease, relied on a CPAP device for non-invasive mechanical ventilation. Observations and interviews revealed that the resident's significant other primarily managed and maintained the CPAP device, with staff involvement limited to turning the device on. The resident expressed uncertainty about staff knowledge regarding the device and reported having to question staff about their competency before allowing them to handle it. Nursing staff and the DON confirmed that there was no formal training provided on the use or troubleshooting of CPAP devices, and no user manual was readily available. Staff described relying on informal methods, such as calling the resident's significant other or searching online, to resolve issues with the device. Documentation showed that while there was a nursing order to clean the CPAP daily, there was no information on device settings or troubleshooting procedures. The facility's policy stated that only qualified and properly trained staff should administer oxygen through a CPAP mask, but did not specify how such training or competency would be ensured. The lack of structured training and clear guidance led to staff uncertainty and inconsistent management of the resident's CPAP device.
Failure to Assess and Address PTSD and Trauma-Informed Care Needs
Penalty
Summary
The facility failed to identify, assess, and document the trauma-related history and PTSD diagnosis for a resident with a known history of military trauma and PTSD. Despite the resident's documented diagnosis of PTSD and anxiety, and a history of serving in Vietnam, the facility did not complete a trauma assessment or evaluate the resident's PTSD. The care plan did not include any triggers or interventions related to managing PTSD, and staff interviews revealed a lack of awareness and understanding of the resident's trauma history and related needs. The facility also lacked a system or process for completing trauma assessments for residents with known trauma histories. Observations and interviews indicated that the resident expressed a preference for being outdoors and discomfort when confined indoors, which was not reflected in the care plan or communicated to all staff. Social services and nursing staff confirmed that there was no screening process for PTSD on admission, and that the care plan did not address trauma-related triggers or interventions. The facility did not have a policy or procedure specific to trauma-informed care, and staff were not consistently aware of the resident's PTSD diagnosis or how to address it in care planning.
Failure to Implement Preventative Maintenance Program for Beds and Side Rails
Penalty
Summary
The facility failed to develop and implement a preventative, regular maintenance program for resident beds and side rails, which resulted in the lack of routine safety inspections and maintenance for all beds and side rails in use. Observations revealed that several residents had beds with bilateral, chrome-colored metallic half side rails that were loose and moved several inches side-to-side when touched, despite being attached to the bed frame. Interviews with residents indicated that they were not consulted about the use of side rails or offered alternative devices prior to installation, and some residents had signed consent forms without being asked about their preferences. Review of facility documentation and interviews with staff, including the DON, facilities manager, and environmental services director, confirmed that there was no ongoing, routine maintenance program for beds or side rails. Maintenance was only performed in response to specific work orders, such as when a side rail was found to be loose or when a resident was discharged and the bed was prepared for a new occupant. The environmental services staff performed monthly bed washes and terminal cleaning but did not check for preventative maintenance or potential entrapment hazards, and these activities were not documented or tracked for maintenance purposes. The facility was unable to provide a policy on bed maintenance, and the provided work order records lacked evidence of any ongoing preventative screening or maintenance review to ensure bed safety. Staff interviews further revealed uncertainty about responsibilities for bed and side rail safety checks, and there was no documentation of routine inspections or adherence to manufacturer recommendations for annual maintenance. These deficiencies had the potential to affect all residents using beds and side rails at the facility.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to ensure a written notification of transfer and/or discharge was sent to the office of the Ombudsman for a resident reviewed for hospitalization. The resident's quarterly minimum data set (MDS) assessment indicated diagnoses including congestive heart failure (CHF), peripheral vascular disease (PVD), diabetes mellitus (DM), hyperlipidemia (HLD), and asthma. Progress notes showed the resident was hospitalized from 11/6/23 until 11/10/23. The medical record lacked evidence of a written notification of transfer being sent to the Ombudsman. The administrator confirmed that the Ombudsman had not been notified of the hospital transfer, and a registered nurse (RN) stated they were unsure of the exact process, which was normally completed by the administrator. The facility policy indicated that a copy of the notice was to be sent to the office of the state long-term care Ombudsman, but this was not done in this case.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide a written notification of the bed hold policy to a resident or their representative during a hospitalization. The resident, who had diagnoses including congestive heart failure, peripheral vascular disease, diabetes mellitus, hyperlipidemia, and asthma, was hospitalized from 11/6/23 until 11/10/23. The medical record lacked evidence of a written bed hold notification. Interviews with the administrator, a licensed practical nurse, and a registered nurse manager confirmed that the facility had not been completing bed holds since before the COVID-19 pandemic. The facility's policy required written notice within 24 hours of transfer, but this was not followed.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mayo Clinic Health System - Lake City | 12.8 mi | ★★★★★ | 5 | 1 |
| The Green Prairie Rehabilitation Center | 16.4 mi | ★★★★★ | 9 | 0 |
| Plum City Care Ctr | 18.1 mi | ★★★★★ | 0 | 0 |
| American Lutheran Home-mondovi | 22.8 mi | ★★★★★ | 5 | 0 |
| St Crispin Living Community | 25.6 mi | ★★★★★ | 15 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.