All citations for Gundersen St Elizabeth's Care Center
State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.
Last standard health inspection on record
June 10, 2026
Showing 1 to 23 of 23 citations
No harm, with potential for more than minimal harm
Provide properly protected cooking facilities.
The home gave a date the problem would be corrected (July 11, 2025).
No harm, with potential for more than minimal harm
Inspect, test, and maintain automatic sprinkler systems.
The home gave a date the problem would be corrected (July 31, 2025).
No harm, with potential for more than minimal harm
Have generator or other power source capable of supplying service within 10 seconds.
The home gave a date the problem would be corrected (June 13, 2025).
No harm, with potential for more than minimal harm
Have exits that are accessible at all times.
The home gave a date the problem would be corrected (May 31, 2024).
No harm, with potential for more than minimal harm
Provide properly protected cooking facilities.
The home gave a date the problem would be corrected (May 31, 2024).
No harm, with potential for more than minimal harm
Have approved installation, maintenance and testing program for fire alarm systems.
The home gave a date the problem would be corrected (May 31, 2024).
No harm, with potential for more than minimal harm
Inspect, test, and maintain automatic sprinkler systems.
The home gave a date the problem would be corrected (April 20, 2024).
No harm, with potential for more than minimal harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
The home gave a date the problem would be corrected (May 1, 2024).
No harm, with potential for more than minimal harm
Have proper medical gas storage and administration areas.
The home gave a date the problem would be corrected (April 3, 2024).
No harm, with potential for more than minimal harm
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
The home gave a date the problem would be corrected (July 31, 2025).
No harm, with potential for more than minimal harm
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
The home gave a date the problem would be corrected (July 31, 2025).
No harm, with potential for more than minimal harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
The home gave a date the problem would be corrected (June 10, 2025).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
The home gave a date the problem would be corrected (July 10, 2026).
No harm, with potential for more than minimal harm
Inspect, test, and maintain automatic sprinkler systems.
The home gave a date the problem would be corrected (July 10, 2026).
No harm, with potential for more than minimal harm
Provide care or services that was trauma informed and/or culturally competent.
The home gave a date the problem would be corrected (August 13, 2025).
No harm, with potential for more than minimal harm
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
The home gave a date the problem would be corrected (July 31, 2025).
No harm, with potential for more than minimal harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
The home gave a date the problem would be corrected (April 26, 2024).
No harm, with potential for minimal harm
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
The home gave a date the problem would be corrected (July 31, 2025).
No harm, with potential for minimal harm
Provide family notifications of emergency plan.
The home gave a date the problem would be corrected (July 31, 2025).
No harm, with potential for minimal harm
Have simulated fire drills held at unexpected times.
The home gave a date the problem would be corrected (June 30, 2025).
No harm, with potential for minimal harm
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
The home gave a date the problem would be corrected (April 26, 2024).
No harm, with potential for minimal harm
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
The home gave a date the problem would be corrected (April 20, 2024).
No harm, with potential for minimal harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
The home gave a date the problem would be corrected (April 20, 2024).
Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.