Cycle 1
Health 2025-12-22 · Fire 2025-12-22
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Hazel Green, WI
St Dominic Villa
1-star overall rating with 1-star inspections with $129,467 in total fines with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
2375 Sinsinawa Rd, Hazel Green, WI
(608) 748-9814
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
62
Certified beds
Average residents
58
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2000-12-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.87
Registered nurse staffing
LPN hours / resident day
0.28
Licensed practical nurse staffing
Aide hours / resident day
2.75
Nurse aide staffing
Weekend hours
3.55
Weekend nurse staffing
RN turnover
58%
Annual RN turnover
Total nurse turnover
44%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.6
0.7 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
2.2
0.4 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.2% |
95.7%
6.5 pts worse
|
93.4%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.4% |
95.0%
1.6 pts worse
|
95.5%
2.1 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
3.2%
1.9 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
5.0%
3.6 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 2.3% |
4.9%
2.6 pts better
|
5.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.0% |
16.6%
6.4 pts worse
|
19.6%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 27.9% |
16.7%
11.2 pts worse
|
16.7%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.9% |
21.1%
7.2 pts better
|
16.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.2% |
17.3%
1.1 pts better
|
14.9%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
2.3%
1.9 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 3.8% |
3.0%
0.8 pts worse
|
1.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.2% |
25.5%
2.3 pts better
|
19.8%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 9.3% |
5.5%
3.8 pts worse
|
5.1%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 62.0% |
86.8%
24.8 pts worse
|
81.7%
19.7 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.1% |
1.3%
1.8 pts worse
|
1.6%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-15 · Fire 2024-08-15
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-04-19 · Fire 2023-04-19
19 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-12-22
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2026-01-22
E · Potential for more than minimal harm
2025-12-22
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2026-01-22
E · Potential for more than minimal harm
2025-12-22
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2026-01-22
E · Potential for more than minimal harm
2025-12-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2026-01-22
D · Potential for more than minimal harm
2025-12-22
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2026-01-22
F · Potential for more than minimal harm
2024-08-15
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-09-16
F · Potential for more than minimal harm
2024-08-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-16
E · Potential for more than minimal harm
2024-08-15
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-16
F · Potential for more than minimal harm
2023-04-19
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-05-19
E · Potential for more than minimal harm
2023-04-19
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-05-19
E · Potential for more than minimal harm
2023-04-19
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-05-19
E · Potential for more than minimal harm
2023-04-19
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-05-19
E · Potential for more than minimal harm
2023-04-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-19
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-19
Inspection history
Recent health citations
J · Immediate jeopardy
2025-12-22
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2026-01-23
F · Potential for more than minimal harm
2025-12-22
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-01-23
D · Potential for more than minimal harm
2025-12-22
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2026-01-23
D · Potential for more than minimal harm
2025-12-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-23
J · Immediate jeopardy
2024-08-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-16
G · Actual harm
2024-08-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-01
F · Potential for more than minimal harm
2024-08-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-16
F · Potential for more than minimal harm
2024-08-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-16
F · Potential for more than minimal harm
2024-08-15
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-09-16
E · Potential for more than minimal harm
2024-08-15
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-15
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-09-16
J · Immediate jeopardy
2024-02-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-12
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-12
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-03-01
G · Actual harm
2023-11-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-09
J · Immediate jeopardy
2023-10-06
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-10-30
F · Potential for more than minimal harm
2023-10-06
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-10-30
F · Potential for more than minimal harm
2023-10-06
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-10-30
D · Potential for more than minimal harm
2023-10-06
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-10-30
D · Potential for more than minimal harm
2023-10-06
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-10-30
D · Potential for more than minimal harm
2023-10-06
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-10-30
D · Potential for more than minimal harm
2023-10-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-30
D · Potential for more than minimal harm
2023-10-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-30
D · Potential for more than minimal harm
2023-10-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-30
D · Potential for more than minimal harm
2023-10-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-30
D · Potential for more than minimal harm
2023-04-19
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-19
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-19
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-19
Penalties and ownership
What sits behind the stars
$49,823
2024-08-15
Fine
Fine · fine $49,823
Fine
$0
2024-08-15
Payment Denial
Payment Denial · denial start 2024-09-13 · 49 days
49 day denial
$79,644
2023-10-06
Fine
Fine · fine $79,644
Fine
$0
2023-10-06
Payment Denial
Payment Denial · denial start 2023-11-03 · 119 days
119 day denial
Ownership
Bruner, Joshua
Operational/Managerial Control · Individual
Droeszler, Zachary
Operational/Managerial Control · Individual
Illuminus Inc
Operational/Managerial Control · Organization
Marks, Julie
Operational/Managerial Control · Individual
Marks, Julie
Corporate Officer · Individual
Mauthe, Matthew
Operational/Managerial Control · Individual
Mauthe, Matthew
Corporate Director · Individual
Mauthe, Matthew
Corporate Officer · Individual
Rogers, Doug
Corporate Director · Individual
Rosemeyer, Joseph
Corporate Director · Individual
Smith, Kenneth
Corporate Director · Individual
Sookochoff, Jesse
Corporate Director · Individual
Southwest Health Center Inc
5% Or Greater Direct Ownership Interest · Organization
Swr1 Inc
5% Or Greater Direct Ownership Interest · Organization
The Hills At Cortland Ridge, Inc.
5% Or Greater Direct Ownership Interest · Organization
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#3
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