St Dominic Villa

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

Met the expected recovery: 45.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 40 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.14 therapist hours per resident per day in 2026Q1 — more than 11% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 62 beds and averages 59.3 residents a day — about 96% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.81 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.72 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.69 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.56 hrs/resident/day on weekends vs 3.92 on weekdays — 9% thinner on weekends. RN hours go from 0.85 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 45% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

34 citations, most serious first. The 16 most serious are shown; the remaining 18 are one tap away and print in full.

• Immediate jeopardy · J2025-12-22 · tag F0700 — isolated
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 1 of 9 reviewed for bedrailsBased on interview and record review, the facility did not ensure other alternatives were tried prior to installing/utilizing bed rails, failed to accurately assess the risk of possible entrapment, failed to identify and recognize the use of an air mattress with bed rails increases the risk for entrapment, failed to re-assess and obtain an updated consent after the installation of an air mattress with bed rails, and care plan the need and use of bed rails for 1 of 9 residents (R11) reviewed for bed rails.R11 did not have alternatives attempted prior to the facility installing and utilizing bed rails.R11's bed rail assessment was not completed accurately.R11's bed rail assessment and consent form were not updated after the installation of an air mattress.R11's comprehensive care plan was not updated with the need and use of bed rails.R11 became entrapped in the bed rail resulting in multiple abrasions, bruises, and redness on R11's inner upper arm, neck, under jaw, face and torso.The…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-08-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that 2 of 2 residents (R) reviewed for pressure injuries (PI) (R36 and R8) received care consistent with professional standards of practice to prevent the development of a new pressure injury and promote healing of existing PIs. R36 was at risk for PI development. R36 developed multiple stage 3 PI's. The facility failed to evaluate the effectiveness of current interventions R36 had in place. The facility did not reposition R36 for several hours, did not find PI's until they were at a Stage 3, missed weekly wound treatments, and did not provide proper infection control measures during wound dressing change. R8 was at risk for PI development. R8 developed multiple stage 3 PI's. The facility failed to evaluate the effectiveness of current interventions R8 had in place. The facility did not reposition R8 for several hours, did not find PI's until they were at a Stage 3, missed weekly wound treatments, and did not provide proper infection…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-02-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that each resident's environment remains as free of accident hazards as possible for 1 of 1 residents (R1). R1 resided in the facility's memory care unit and has a history of tossing her leg onto the heat register next to her bed. On 1/15/24, R1 was found to have placed her foot on the heat register next to her bed. This resulted in burns to R1's left lateral foot (full thickness), left foot (undetermined thickness) and right foot (undetermined thickness) that required physician intervention. The facility does not routinely monitor the temperature of the heat registers. The facility's failure to provide proper safety interventions to prevent accidents and monitor resident's rooms and environment created a finding of Immediate Jeopardy that began on 1/15/24. Surveyor notified the NHA A (Nursing Home Administrator) of the Immediate Jeopardy on 2/1/24 at 6:00 PM. The Immediate Jeopardy was removed on 2/2/24; however, the deficient…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-10-06 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 9/20/23 at 10:07 AM, surveyor interviewed CNA D (Certified Nursing Assistant) who indicated that there have been times she was not able to complete job duties, including baths, due to staffing. On 9/20/23 at 10:22 AM, surveyor interviewed LPN C (Licensed Practical Nurse) regarding staffing, LPN C stated, staff is very frustrated. LPN C indicated that CNA staff report to her that there in not enough time to get showers/baths completed. LPN C indicated there was times she was not able to perform wound care due to staffing issues. LPN C indicated nursing floor staff has to adjust the wound care schedules to allow for nursing floor staff to be able to complete all wound care. Based on observation, interview, and record review the facility failed to ensure that 5 of 13 sampled residents (R2, R10, R13, R9, R14) were free from neglect. Numerous staff expressed concerns about low staffing levels and not being able to provide all needed care because there isn't enough staff. R2 had a history of recurrent Urinary Tract…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-08-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed for accidents (R54). R54 was a known fall risk and the facility did not follow her plan of care, resulting in a fall with fracture. Findings include: The facilities fall policy states the following: *Prevention measures are put in place to reduce the occurrence of falls in risk of injury from falls. *Licensed nurse completes electronic documentation of the fall instant report *The care plan will be updated with an identified intervention *Registered nurse reviews and completes the fall assessment and interventions *Fall follow up assessments completed as indicated *The interdisciplinary team will review fall incident report and utilize root cause analysis to make further recommendations. *The director of nursing and executive director to review & fall incident reports. R54 was admitted to the facility on [DATE] and has diagnoses…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-11-30 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that a resident receives treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 4 sampled Residents (R2). R2 had a change in condition that was not identified timely by nursing staff resulting in hospitalization for fluid overload. This is evidenced by: The facility policy entitled, 'Change of Condition and Provider Notification,' states in part: .Upon individual change of condition, proper assessment and provider notification will occur to provide timely delivery of clinical care. II. Procedure: 1. Change of condition. a) change of condition (COC) is a deviation from an individual's baseline in physical, cognitive, behavioral, or functional status. Clinically important means a deviation that, without intervention, may result in complications or death. 2. Assessment. a) licensed nurse is involved in the assessment process and contributes to the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-12-22 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 59 residents.Visible dust was observed over a food preparation area. Food was improperly dated. Example 1On 12/9/25 at 11:01 AM, Surveyor observed, with DM E (Dietary Manager), the main kitchen's hood vents with visible clumps of dust on them and hanging off. Directly underneath the hood vents is a stove top and griddle where two pots of food were observed cooking. DM E was asked if he felt the hood vents were clean to which he replied, No, I can see some dust bunnies up there. Example 2 On 12/9/25 at 10:40 AM, Surveyor observed the following food items and corresponding dates:*Cocoa in a container dated 8/8 with no use by or expiration date.*Cheerios in a container, dated 11/25 with no use by or expiration date.*Modified bread mix in a container, dated 6/20, use by 7/20.*Three containers of pasta, one marked 10/25, use by 11/25, another marked 10/10, use by 11/10,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-22 · tag F0740 — failed to provide behavioral / mental-health care — isolated
  Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not provide behavioral health services to ensure the highest practicable mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 15 residents (R6) reviewed. R6 admitted to the facility with a history of post-traumatic stress disorder (PTSD). The facility failed to include PTSD on R6's comprehensive plan of care, nor were staff aware of any of R6's PTSD triggers. This is evidenced by: The National Institutes for Health states, in part: .PTSD can develop after exposure to a potentially traumatic event that is beyond a typical stressor. Events that may lead to PTSD include, but are not limited to, violent personal assaults, natural or human-caused disasters, accidents, combat, and other forms of violence. Exposure to events like these is common. People who experience PTSD may have persistent, frightening thoughts and memories of the event(s), experience sleep problems, feel detached or numb, or may be easily…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-22 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 wound care observations. Staff did not perform hand hygiene in between glove changes during wound care for R48. Evidenced by:The facility policy entitled Hand Hygiene, dated 12/5/2024, states, in part: . I. Policy: The organization will promote clean hands as the single most important factor in preventing the spread of pathogens, antibiotic resistance, and incidence of infections. II. Procedure: A. Specific Indications for Hand Hygiene.4. After touching a patient or the patient's immediate environment.6. Immediately after glove removal. Evidenced by:R48 admitted to the facility on [DATE] and has diagnoses that include Type II Diabetes Mellitus (Type 2 diabetes happens when the body cannot use insulin correctly and sugar builds up in…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2024-08-15 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 59 residents. Food items were found undated or beyond their use by date in various locations in the facility. Staff were observed in the kitchen without hair nets. Findings include The facility policy titled Food from Outside Sources, states, All cooked or prepared food brought in for a resident and stored in the unit's pantry refrigerator or personal room refrigerator will be dated when accepted for storage and discarded after five days. Nursing staff will monitor resident's room, unit pantry, and refrigeration units for food and beverage disposal. Example 1 On 8/12/24 at 9:48 AM, during initial tour of the facility's main kitchen, Surveyors observed the following: *A bag of flour open with an open date of 6/17 and use by date of 7/17 with no year indicated. *8 oz thickened chocolate milk, opened, with no open date and manufacturer's use by date of 9/25/24 *Lemonade…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2024-08-15 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that there was a system in place for standard transmission-based precautions to be followed to prevent the spread of infections. This had the potential to affect all 59 residents. The facility failed to do the following: The facility has one (2) resident's that tested positive for COVID 19. The facility did not complete contact tracing or broad-base testing of all residents to identify if others were COVID positive. The facility is only testing residents when they are symptomatic therefore the facility would have no way to know if they are in an outbreak due to not testing all residents. The facility is not utilizing source control on the affected unit. The facility does not have their agency staff N95 fit tested. Surveyor observed KN95s were not available in the COVID positive room's isolation cart where an agency staff was on duty. Surveyor observed staff not don (put on) appropriate personal protective equipment (PPE) when entering a COVID…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2024-08-15 · tag F0882 — widespread
  Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interview and record review, the facility did not ensure a staff person designated as the Infection Preventionist (IP) completed specialized training in infection prevention and control. This practice had the potential to affect all 59 residents residing in the facility. IP/ADON P (Infection Preventionist) and DON B (Director of Nursing) did not complete specialized training for infection prevention and control. Findings include: The facility's Infection Prevention and Control policy and procedure, last reviewed September 2023, indicates: The IP (Infection Preventionist) will maintain current knowledge in the field of infectious disease and epidemiology through training provided through the CDC (Centers for Disease Control and Prevention) in collaboration with Centers for Medicare and Medicaid (CMS). On 8/14/24 at 9:35 AM, Surveyor interviewed IP/ADON P who verified IP/ADON P started as the IP in June of 2024 and did not have specialized infection control training. IP/ADON P stated IP/ADON P was informed about the required training and she has started working on the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-08-15 · tag F0607 — failed to have anti-abuse policies — pattern
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 4 (LPN C, LPN W, Maintenance Supervisor X, RN V) of 8 employees reviewed. The facility did not ensure their abuse policy was implemented when four employees' background information disclosure (BID) was not obtained before employees started working at facility. (LPN C, LPN W, Maintenance Supervisor X, and RN V). Findings include: The facility policy, entitled Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, revised, December 2022 states in part Employee screening and training: a. Before new employees are permitted to work with resident's board registrations and certifications regarding prospective employee's background will be checked. d. A criminal background check will be conducted on all prospective employees as provided by the facility's policy on criminal background checks. On 08/13/24 at 8:14 AM, Surveyor reviewed 8 random…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-15 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to consult with the physician related to a significant change of condition for 1 of 7 residents (R46) out of 15 residents reviewed for physician notification. The facility did not consult with R46's physician after a culture and sensitivity (C&S) report confirmed he had a urinary tract infection. As evidenced by The facility's policy, Change of Condition and Provider Notification, reviewed 8/10/23, indicates, in part, the following: Upon individual change of condition, proper assessment and provider notification will occur to provide timely delivery of clinical care. Procedure: Change of Condition (COC) is a deviation from an individual's baseline in physical, cognitive, behavioral, or functional status. Clinically important means a deviation that, without intervention, may result in complications or death. Notification: Primary Care Provider (PCP) will be contacted for notification and obtain further orders from provider as necessary. If PCP cannot be…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-08-15 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a comprehensive assessment was completed for 1 (R21) of 7 residents reviewed for change of condition. R21 had an unresponsive episode, and the facility did not complete a full assessment or notify the physician (MD). R21 could not find his words the facility did not complete a full assessment or notify the MD. This is evidenced by: The facility utilizes Interventions to Reduce Acute Care Transfers, or Interact, as the facility's standard of practice. According to Interact II Signs and Symptoms to report immediately to a physician include: Consciousness, altered: Sudden change in level of consciousness or responsiveness. Speech Abnormality: Abrupt change in speech with or without other neurological findings. R21 was admitted to the facility on [DATE] with diagnoses including Bipolar disorder, Diabetes Mellitus, History of TIA (Transient Ischemic Attack-Mini stroke), seizure disorder, obesity, and sleep apnea. It should be noted R21 wishes to have…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-15 · tag F0729 — isolated
  Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview, the facility did not ensure that 1 CNA T (Certified Nursing Assistant) of 5 staff reviewed for verification of a current Nurse Aide Registry were on the Wisconsin registry before starting work in the facility. CNA T was not on the Wisconsin Nurse Aide Registry and was working in the facility at the time of the discovery. Findings include: On 8/13/24, Surveyor reviewed five (5) random CNA's as part of the background check process. CNA T was hired on 6/3/24. NHA A (Nursing Home Administrator) provided a state of Iowa CNA registry certificate for CNA T. CNA T was not on the Wisconsin CNA registry. On 8/13/24 at 11:15 AM, Surveyor interviewed NHA A about the missing Wisconsin CNA Registry for CNA T. NHA A stated CNA T had applied for the Wisconsin registry on 8/9/24. NHA A did not provide a copy of the Wisconsin registry application as requested. NHA A thought CNA T could work in the facility while the application was pending. According to the Wisconsin Nurse Aide Training and Registry, nurse aides must be listed on the Wisconsin Nurse Aide Registry…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$129,467 in federal fines across 2 penalties. 2 Medicare payment denials on record.

• $49,823 — penalty dated 2024-08-15
• $79,644 — penalty dated 2023-10-06
• Medicare payment denial — starting 2024-09-13 for 49 days
• Medicare payment denial — starting 2023-11-03 for 119 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to ILLUMINUS — 5 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 20 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.

4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in WI