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

Compare this facility

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

Certified beds

Average residents

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

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.87

Registered nurse staffing · state 0.97 · national 0.68

LPN hours / resident day

0.28

Licensed practical nurse staffing · state 0.64 · national 0.87

Aide hours / resident day

2.75

Nurse aide staffing · state 2.59 · national 2.35

Total nurse hours

3.90

All reported nurse hours · state 4.20 · national 3.89

Licensed hours

1.15

RN + LPN hours · state 1.60 · national 1.54

Weekend hours

3.55

Weekend nurse staffing · state 3.72 · national 3.43

Weekend RN hours

0.58

Weekend registered nurse coverage · state 0.66 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

1.02

CMS adjusted RN staffing hours

Adjusted total hours

4.60

CMS adjusted total nurse staffing hours

Case-mix index

1.16

Higher values indicate more complex resident acuity

RN turnover

58%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

44%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,756

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

10.66

Composite VBP score used to determine payment impact.

Payment multiplier

0.9809

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

Baseline 62.50% · Performance 69.23% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

2.13

Baseline 2.78 hours · Performance 3.57 hours · Measure score 2.13 · Achievement 1.73 · Improvement 2.13

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.13%	10.72% 0.6 pts better	No Different than the National Rate · Eligible stays 33 · Observed rate 6.06% · Lower 95% interval 6.57%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	0.71	1.02 0.3 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 42 · Denominator 42
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 42
Discharge self-care score	40.63%	53.69% 13.1 pts worse	Numerator 13 · Denominator 32
Discharge mobility score	31.25%	50.94% 19.7 pts worse	Numerator 10 · Denominator 32
Pressure ulcers or injuries, new or worsened	4.76%	2.29% 2.5 pts worse	Numerator 2 · Denominator 42 · Adjusted rate 4.88%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	35.44%	8.2% 27.2 pts better	Numerator 28 · Denominator 79
Staff flu vaccination coverage	60.23%	42% 18.2 pts better	Numerator 53 · Denominator 88
Discharge function score	34.38%	56.45% 22.1 pts worse	Numerator 11 · Denominator 32
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.

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 · Adjusted 0.9 · Observed 0.8 · Expected 1.5 · Used in QM five-star
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 · Adjusted 2.6 · Observed 2.4 · Expected 1.5 · Used in QM five-star
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 · Q1 82.5% · Q2 86.7% · Q3 92.5% · Q4 96.2% · 4Q avg 89.2%
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 · 4Q avg 93.4%
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 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 3.8% · 4Q avg 1.3% · Used in QM five-star
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 · Q1 5.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4%
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 · Q1 0.0% · Q2 0.0% · Q3 7.7% · Q4 2.4% · 4Q avg 2.3%
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 · Q1 22.4% · Q2 22.0% · Q3 23.3% · Q4 24.4% · 4Q avg 23.0%
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 · Q1 25.6% · Q2 26.2% · Q3 32.3% · Q4 28.6% · 4Q avg 27.9% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
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 · Q1 20.4% · Q2 16.5% · Q3 15.6% · Q4 0.0% · 4Q avg 13.9% · Used in QM five-star
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 · Q1 21.3% · Q2 14.6% · Q3 17.1% · Q4 11.6% · 4Q avg 16.2% · Used in QM five-star
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 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
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 · Q1 3.7% · Q2 5.0% · Q3 4.1% · Q4 2.0% · 4Q avg 3.8% · Used in QM five-star
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 · Q1 20.1% · Q2 28.4% · Q3 21.3% · Q4 22.1% · 4Q avg 23.2%
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 · Q1 8.0% · Q2 13.3% · Q3 7.7% · Q4 7.6% · 4Q avg 9.3% · Used in QM five-star
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 · Q3 72.7% · Q4 80.0% · 4Q avg 62.0%
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 · 4Q avg 3.1% · Used in QM five-star

Survey summary

Recent inspection cycles

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)

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