St Dominic Villa
2375 Sinsinawa Rd, Hazel Green, WI 53811 · Grant County · 62 certified beds · avg 59 residents/day · certified since Dec 8, 2000
Part of chain: ILLUMINUS (5 facilities, chain avg rating 2.0★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · 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 · Dec 22, 2025 · F-0700
The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly.
Why it matters: Improperly used bed rails can trap or injure residents — in the worst cases, causing serious 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: Jan 23, 2026 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Aug 15, 2024 · F-0686
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.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
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: Sep 16, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Feb 12, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
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: Mar 1, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Oct 6, 2023 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
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: Oct 30, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 15, 2024 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
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: Nov 1, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 30, 2023 · 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 (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 9, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (34)
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 |
|---|---|---|
| Dec 22, 2025 | ▲ J · Immediate jeopardy, one-off | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Dec 22, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Dec 22, 2025 | D · Potential for harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. |
| Dec 22, 2025 | 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. |
| Aug 15, 2024 | ▲ J · Immediate jeopardy, 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. |
| Aug 15, 2024 | ▲ G · Actual 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. |
| Aug 15, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 15, 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. |
| Aug 15, 2024 | F · Potential for harm, facility-wide | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. |
| Aug 15, 2024 | E · Potential for harm, repeated | 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. |
| Aug 15, 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. |
| Aug 15, 2024 | 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. |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility did not verify that its nurse aides had completed their required training, or did not retrain aides who had been out of nurse aide work for 2 years. |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Aug 15, 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. |
| Feb 12, 2024 | ▲ J · Immediate jeopardy, 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 |
| Feb 12, 2024 | D · Potential for harm, one-off | The facility did not make sure the resident's doctor reviewed their care and wrote, signed, and dated progress notes and orders at each required visit. · from a complaint |
| Feb 12, 2024 | D · Potential for harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint |
| Nov 30, 2023 | ▲ G · Actual 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 |
| Oct 6, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Oct 6, 2023 | 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 6, 2023 | F · Potential for harm, 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. · from a complaint |
| Oct 6, 2023 | 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 |
| Oct 6, 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 |
| Oct 6, 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 |
| Oct 6, 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 |
| Oct 6, 2023 | 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 |
| Oct 6, 2023 | 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 |
| Oct 6, 2023 | 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 |
| Apr 19, 2023 | 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. |
| Apr 19, 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. |
| Apr 19, 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. |
| Apr 19, 2023 | 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. |
| Apr 19, 2023 | 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. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (11 → 4).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 16 | 2 | J ▲ |
| 2024 | 14 | 3 | J ▲ |
| 2025 | 4 | 1 | J ▲ |
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 $129,467, plus 2 Medicare payment denial periods.
| Date | Type | Amount / length |
|---|---|---|
| Aug 15, 2024 | Fine | $49,823 |
| Aug 15, 2024 | Payment Denial | 49 days from Sep 13, 2024 |
| Oct 6, 2023 | Fine | $79,644 |
| Oct 6, 2023 | Payment Denial | 119 days from Nov 3, 2023 |
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) | 4.64 | 4.29 | 3.95 | top 31% in Wisconsin; top 20% in the U.S. |
| Registered Nurse hours | 0.87 | 1.01 | 0.69 | bottom 44% in Wisconsin; top 22% in the U.S. |
| Weekend total nurse staffing | 4.33 | 3.84 | 3.50 | top 27% in Wisconsin; top 15% 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 (%) | 45.2 | 46.9 | 45.8 | top 46% in Wisconsin; bottom 49% in the U.S. |
| RN turnover (%) | 35.7 | 39.7 | 42.9 | top 46% in Wisconsin; top 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 3.81, RN 0.72, weekend 3.56. Staffing rating: 5/5.
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: 3/5 · long-stay residents: 3/5 · short-stay residents: 2/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Southwest Health Center INC | Organization | 5% or Greater Direct Ownership Interest | — | 06/10/2020 |
| SWR1 INC | Organization | 5% or Greater Direct Ownership Interest | — | 06/10/2020 |
| The Hills at Cortland Ridge, INC. | Organization | Direct Ownership Interest | NOT APPLICABLE | 06/10/2020 |
| Bruner, Joshua | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/06/2024 |
| Bruner, Joshua | Individual | ADP of the SNF | NOT APPLICABLE | 04/25/2025 |
| Droeszler, Zachary | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/01/2024 |
| Droeszler, Zachary | Individual | ADP of the SNF | NOT APPLICABLE | 08/01/2024 |
| Illuminus INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 06/10/2020 |
| Illuminus INC | Organization | ADP of the SNF | NOT APPLICABLE | 10/17/2025 |
| Marks, Julie | Individual | Corporate Officer | NOT APPLICABLE | 06/09/2025 |
| Marks, Julie | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/09/2025 |
| Marks, Julie | Individual | ADP of the SNF | NOT APPLICABLE | 06/09/2025 |
| Mauthe, Matthew | Individual | Corporate Director | NOT APPLICABLE | 06/10/2020 |
| Mauthe, Matthew | Individual | Corporate Officer | NOT APPLICABLE | 06/10/2020 |
| Mauthe, Matthew | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/10/2020 |
| Mauthe, Matthew | Individual | ADP of the SNF | NOT APPLICABLE | 06/10/2020 |
| Rogers, Doug | Individual | Corporate Director | NOT APPLICABLE | 12/01/2020 |
| Rosemeyer, Joseph | Individual | Corporate Director | NOT APPLICABLE | 11/01/2024 |
| Smith, Kenneth | Individual | Corporate Director | NOT APPLICABLE | 11/01/2024 |
| Sookochoff, Jesse | Individual | Corporate Director | NOT APPLICABLE | 12/01/2020 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What alternatives do you try before using bed rails, and how do you involve families in that decision?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "What mental health services do you provide on-site, and who delivers them?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "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 |
|---|---|---|---|---|---|
| Sunnycrest Manor | 6.1 mi | Dubuque, IA | ★★★★☆ | 4/5 | |
| Bethany Home | 6.3 mi | Dubuque, IA | ★★★★★ | 4/5 | |
| Stonehill Care Center | 6.7 mi | Dubuque, IA | ★★★★☆ | 4/5 | |
| Mount Carmel Bluffs | 6.8 mi | Dubuque, IA | ★★★★★ | 4/5 | |
| Harmony Dubuque | 7.2 mi | Dubuque, IA | ★★☆☆☆ | 2/5 | |
| Dubuque Specialty Care | 8.7 mi | Dubuque, IA | ★★☆☆☆ | 2/5 | |
| Galena Stauss Nursing Home | 8.8 mi | Galena, IL | ★★★☆☆ | 3/5 | |
| Luther Manor at Hillcrest | 9.1 mi | Dubuque, IA | ★☆☆☆☆ | 1/5 | |
| Ennoble Nursing and Rehab | 9.3 mi | Dubuque, IA | ★★★★★ | 5/5 | |
| Grand Meadows Senior Living & Health Care | 11.0 mi | Asbury, IA | ★☆☆☆☆ | 2/5 | |
| Hawkeye Care Center Dubuque | 11.4 mi | Asbury, IA | ★★★☆☆ | 3/5 | |
| Edenbrook of Platteville | 15.9 mi | Platteville, WI | ★★★★☆ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 525660.