Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Dominic Villa during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple chronic conditions was placed in bed rails without documented trial of alternatives, and the side rail assessment and consent were not updated after an air mattress was added. The resident was later found entrapped in the rails with the head and arm wedged through the bars and sustained multiple abrasions, bruises, and redness. The record also showed the care plan did not include the bed rails or the need for them.
Improper Food Storage and Unsanitary Kitchen Conditions: The kitchen hood vents above the cooking area had visible dust and hanging debris while food was being prepared underneath. Multiple stored food items were also improperly dated, including items with no use-by or expiration dates and items dated beyond their use-by dates. The Dietary Manager acknowledged the vents were not clean and that the cocoa should have had a use-by or expiration date.
A resident with documented PTSD, anxiety, and other mental health diagnoses did not have PTSD or trauma triggers included in the care plan. The resident’s record, MDS, trauma screening, and BH note all identified PTSD, but staff were unaware of the diagnosis and did not know the resident’s triggers, including distress related to eating in the dining room. Interviews with CNA, SW, DON, and ADON confirmed the diagnosis was not reflected on the care plan or CNA Kardex.
Failure to Perform Hand Hygiene During Wound Care: An LPN performed wound care on a resident with Type II DM and a stage 3 pressure ulcer without hand hygiene between glove changes. The LPN also touched the curtain and bed control and continued care without changing gloves or cleaning hands. The ADON stated hand hygiene would be expected between glove changes when touching items in between.
Two residents in a long-term care facility developed multiple stage 3 pressure injuries due to inadequate care and prevention measures. The facility failed to evaluate the effectiveness of interventions, did not reposition residents as required, and missed weekly wound treatments. Infection control measures were also not followed during wound dressing changes, contributing to the worsening of the residents' conditions.
A resident with severe cognitive impairment and a high risk of falls experienced multiple falls, including one resulting in a spinal fracture, due to inadequate supervision and delayed implementation of safety interventions. The facility failed to consistently follow the care plan, which included keeping the resident in view during high-risk times and ensuring the wheelchair did not have footrests unless being transported. Despite the known fall risk, necessary equipment like a bed/chair alarm was not promptly available, contributing to the resident's repeated falls and injury.
The facility failed to adhere to professional standards for food safety, with undated or expired food items found in various locations and staff not following hygiene protocols, such as wearing hair nets in the kitchen.
The facility failed to implement effective infection control measures, including contact tracing and broad-based testing, after two residents tested positive for COVID-19. Staff did not consistently use appropriate PPE, and agency staff were not fit tested for N95 masks. Additionally, the facility's pneumococcal vaccination policy was outdated, and equipment sanitation was neglected.
The facility did not ensure that the designated Infection Preventionist (IP) and the Director of Nursing (DON) completed specialized training in infection prevention and control. The IP, who started in June 2024, had not completed the necessary CDC training modules, and the DON, who served as the IP from February to June 2024, also did not complete any required training. This deficiency had the potential to affect all 59 residents in the facility.
The facility did not implement its policies for screening employees for abuse, neglect, or exploitation history. Four employees, including two LPNs, a Maintenance Supervisor, and an RN, had incomplete or missing Background Information Disclosure forms, contrary to the facility's policy requiring background checks before employment.
A resident with a history of urinary issues and cancer experienced a significant change in condition with a confirmed UTI. The facility failed to promptly notify the urologist, resulting in a five-day delay in receiving necessary antibiotics. Despite the facility's policy for timely provider notification, there was no documented follow-up with the urologist, leading to a delay in treatment.
A resident with a history of TIAs and seizure disorder experienced unresponsiveness and speech difficulties, but the facility failed to conduct a comprehensive assessment or notify the physician. Despite using Interact II guidelines, which require immediate MD notification for such changes, the facility did not follow protocol. Interviews with staff revealed awareness of the need for assessment and notification, but the DON initially dismissed the symptoms as normal behavior.
A CNA was employed and worked with residents without being listed on the Wisconsin Nurse Aide Registry. The CNA was hired with an Iowa registry certificate, and the NHA mistakenly believed the CNA could work while awaiting Wisconsin registry approval, which is not permitted.
A survey revealed a 10.26% medication error rate in an LTC facility, involving three residents. Errors included a timing error with insulin administration, a dosing error with crushed extended-release medication, and an omission error due to unavailable eye drops. The DON confirmed expectations for adherence to physician orders and medication availability.
A significant medication error occurred when an RN crushed and administered Metoprolol Succinate Extended Release to a resident, contrary to facility policy and physician orders. The RN admitted the error, and the DON confirmed that such actions are unacceptable without specific physician orders.
Bed Rail Assessment, Consent, and Entrapment Failure
Penalty
Summary
The facility did not ensure other alternatives were tried before installing and using bed rails for a resident with significant cognitive impairment and multiple medical conditions, including atrial fibrillation, stage 3 chronic kidney disease, metabolic encephalopathy, a history of falls, and macular degeneration. The resident’s BIMS score showed severe cognitive impairment, and the side rail assessment completed on 8/1/25 indicated that a side rail or grab bar was not indicated, that the resident did not have an alteration in safety awareness due to cognitive deficit, and that the resident could not be caught between the rails or openings. Despite this, a consent form for side rails was signed by the resident’s representative on the same date, even though the assessment stated informed consent should be obtained after alternatives were attempted and after identifying the medical need and alternatives tried. The resident’s comprehensive care plan did not include the use of bed rails, the medical need being addressed by the rails, or the alternatives attempted before their use. The record also showed that an air mattress was added later, but the side rail assessment and consent were not updated after that change. The DON stated that a new assessment and updated consent were not completed because the risk for entrapment was believed not to have changed when the mattress was switched to an alternating air mattress. The report also states that the facility did not recognize that using an air mattress with bed rails increases the risk for entrapment. On 11/16/25, the resident became entrapped in the bed rail. Nursing documentation stated the resident was found with the left arm wedged under the side rail bar and the head wedged through the side rail bars, with feet hanging over the bed. Multiple abrasions, bruises, and redness were noted on the lower left leg, inner upper left arm, neck, under jaw, face, and left side of the torso. The resident was unable to describe the incident. Staff and the DON were notified, and the resident’s family had previously signed a risk-benefit form for continued side rail use. The report also states that no alternatives such as therapy or a trapeze had been attempted before the rails were used.
Improper Food Storage and Unsanitary Kitchen Conditions
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards for food service safety. During observation with the Dietary Manager, the main kitchen hood vents above the stove top and griddle had visible clumps of dust and hanging dust, and two pots of food were cooking directly underneath. When asked, the Dietary Manager stated the hood vents were not clean and said he could see "dust bunnies" on them. In addition, multiple food items in storage were improperly dated, including cocoa in a container dated 8/8 with no use-by or expiration date, Cheerios dated 11/25 with no use-by or expiration date, modified bread mix dated 6/20 with a use-by date of 7/20, and three containers of pasta with varying dates, including one with no opened, use-by, or expiration dates. The Dietary Manager stated the items were marked that way because he felt they would be used by the stated use-by date, and also stated the cocoa should have had a use-by or expiration date.
Failure to Include PTSD and Triggers in Care Plan
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for one resident with a documented history of PTSD. The resident was admitted with multiple mental health diagnoses, including PTSD, anxiety disorder, bipolar disorder, obsessive-compulsive disorder, insomnia, suicidal ideations, and a personal history of suicidal behavior. The resident’s most recent MDS identified PTSD as an active diagnosis, and the resident’s trauma-informed care screening documented multiple traumatic experiences and reported disturbing memories and symptoms related to those events. Despite this information being present in the record, the resident’s comprehensive care plan did not include PTSD or the resident’s trauma triggers. The record also showed a behavioral health note listing PTSD as an active mental health problem. The facility’s trauma-informed care policy stated that individuals would be screened for trauma exposure and that care plans would be established collaboratively with trauma-informed care in mind, but the resident’s care plan did not reflect the diagnosis or related triggers. During interview, the resident stated that staff were not aware of the PTSD or the resident’s triggers. The resident described trauma-related experiences from childhood and stated that food was a trigger because of difficulty eating in front of others due to hand damage and spilling. The resident said staff tried to make the resident eat in the dining room, which caused distress. Staff interviews showed that multiple direct care staff were unaware of the PTSD diagnosis or why the resident avoided the dining room, and the CNA Kardex did not list PTSD. The SW and DON acknowledged that PTSD and the resident’s triggers should be on the care plan, and the ADON stated that PTSD should be included on the resident’s care plan.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility did not establish 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 during wound care for one resident. The resident had diagnoses including Type II Diabetes Mellitus and a stage 3 pressure ulcer of the left ankle. The resident’s MDS Quarterly Assessment dated 11/4/2025 showed no BIMS score, indicating the resident was not cognitively intact. On 12/10/25 at 9:52 AM, an LPN was observed performing wound care on the resident. During the procedure, the LPN removed gloves and put on new gloves without performing hand hygiene in between. The LPN also pulled the resident’s curtain and raised the bed with the foot board control, then continued wound care without changing gloves or completing hand hygiene. When interviewed, the LPN stated hand hygiene should be performed when going from dirty to clean and acknowledged it should have been performed with glove removal. The ADON also stated hand hygiene would be expected in between glove changes if touching things in between and said she would have expected hand hygiene in between glove changes and after touching the curtain and bed control.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to the development of multiple stage 3 pressure injuries. The facility did not evaluate the effectiveness of current interventions for these residents, who were at risk for pressure injuries. Both residents were not repositioned for several hours, and their pressure injuries were not identified until they reached stage 3. Additionally, the facility missed weekly wound treatments and did not adhere to proper infection control measures during wound dressing changes. One resident, who had severe cognitive impairment and was totally dependent on staff for bed mobility and repositioning, developed multiple stage 3 pressure injuries. Despite having care plans in place, the facility did not monitor or document changes in the resident's skin status effectively. The resident was observed not being repositioned or toileted for extended periods, and wound care was not performed according to professional standards. The facility also failed to document new open areas on the resident's ankle, and infection control practices were not followed during wound dressing changes. Another resident, with moderate cognitive impairment and dependent on staff for mobility and toileting, also developed stage 3 pressure injuries. The facility did not follow its protocols for repositioning and off-loading pressure, and wound care assessments were missed. The resident's care plan included pressure-relieving devices, but these were not effectively utilized. The facility's failure to implement and monitor appropriate interventions contributed to the development and worsening of pressure injuries in both residents.
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident identified as a high fall risk. The resident, who has severe cognitive impairment due to dementia, experienced multiple falls over a period of time, including a significant fall that resulted in a new spinal fracture. Despite being aware of the resident's fall risk and history of falls, the facility did not consistently follow the care plan interventions, such as keeping the resident in view during high-risk times and ensuring the resident's wheelchair did not have footrests unless being transported. The resident's care plan included specific interventions to mitigate fall risks, such as supervision during sundowning times and wheelchair management without foot pedals. However, the facility staff failed to maintain visual supervision of the resident, particularly during times identified as high risk for sundowning behaviors. Interviews with staff revealed that the resident was known to be impulsive and restless, often attempting to get up from her wheelchair, which increased her risk of falls. Despite these known behaviors, the facility did not have adequate measures in place to prevent the resident from falling. On one occasion, the facility's intervention to use a bed/chair alarm was delayed due to unavailability, and the resident continued to fall, resulting in further injury. The facility's failure to implement timely and effective interventions, as outlined in the resident's care plan, contributed to the resident's repeated falls and subsequent injury. The lack of immediate availability of necessary equipment, such as the bed/chair alarm, further exacerbated the situation, highlighting a deficiency in the facility's ability to provide a safe environment for the resident.
Deficiency in Food Safety and Hygiene Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, potentially affecting all 59 residents. During an initial tour of the facility's main kitchen, surveyors observed several food items that were either undated or beyond their use-by date. These included an open bag of flour with an open date of 6/17 and a use-by date of 7/17, thickened chocolate milk with no open date, lemonade with no dates, and various juices with no preparation or use-by dates. The Dietary Manager was unsure about the duration the flour had been in the facility and acknowledged that the milk and juices should have been dated when opened. In the memory care kitchen refrigerator, a pitcher of orange juice and a Wendy's cheeseburger were found without proper dating, and in the main dining room refrigerator, pitchers of juice and a bag of mixed fruits were also undated. Additionally, the facility did not ensure that staff adhered to proper hygiene standards in the kitchen. A Certified Nursing Assistant was observed in the main kitchen without a hair net, with her hair down and extending halfway between her shoulders and waist, while conversing with other dietary staff near a food preparation counter. This lack of adherence to food safety and hygiene protocols indicates a deficiency in maintaining professional standards for food service safety within the facility.
Inadequate Infection Control and PPE Usage in LTC Facility
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, which had the potential to affect all 59 residents. The facility did not conduct contact tracing or broad-based testing after two residents tested positive for COVID-19, relying only on testing symptomatic individuals. This approach left the facility unaware of the full extent of the outbreak. Additionally, the facility did not utilize source control measures on the affected unit, and agency staff were not fit tested for N95 masks. Observations revealed that staff did not consistently don appropriate personal protective equipment (PPE) when entering COVID-positive residents' rooms, and isolation carts lacked necessary PPE supplies. The facility's infection control practices were further compromised by inadequate signage and communication regarding isolation protocols. A physician entered a COVID-positive resident's room without PPE, and staff were observed not wearing eye protection or using proper masks. The facility's pneumococcal vaccination policy was outdated, and there was no process in place to administer the recommended vaccines. Additionally, the facility's antibiotic stewardship policy was not effectively implemented, as there was no sensitivity report for an antibiotic prescribed to a resident returning from the hospital. Equipment sanitation between uses was also neglected, as observed when staff did not clean a Hoyer lift after use. The facility's failure to adhere to CDC guidelines and its own policies regarding outbreak management, PPE usage, and vaccination protocols contributed to the deficiencies identified by the surveyors.
Inadequate Training for Infection Preventionist and DON
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) and the Director of Nursing (DON) completed specialized training in infection prevention and control, as required by the facility's policy. The policy, last reviewed in September 2023, mandates that the IP maintain current knowledge in infectious disease and epidemiology through training provided by the CDC in collaboration with CMS. The IP, who started in June 2024, had not completed the necessary training modules at the time of the survey. Although the IP had begun working on the CDC training modules, only a few were completed, some during the survey itself after infection control concerns were identified. The DON, who served as the IP from February to June 2024, also did not complete any of the required CDC training modules. During interviews, both the IP and the DON confirmed their lack of specialized training in infection prevention and control. This deficiency had the potential to affect all 59 residents residing in the facility, as the staff responsible for infection prevention lacked the necessary training to effectively manage and control infections within the facility.
Failure to Implement Employee Screening Policies
Penalty
Summary
The facility failed to implement its policies and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property. This deficiency was identified for four employees: two LPNs, a Maintenance Supervisor, and an RN. The facility's policy, revised in December 2022, mandates that before new employees are allowed to work with residents, their background, including criminal checks, must be verified. However, the surveyor found that the Background Information Disclosure (BID) forms for these employees were either incomplete or not obtained before they started working. Specifically, the BID for one LPN indicated residency in Texas, but no BID was completed for that state. Another LPN's BID was not completed until over a year after their hire date. The Maintenance Supervisor's BID was also missing, and the RN's BID indicated residency in Iowa, but no BID was completed for that state. The surveyor confirmed with the facility's Scheduler and Nursing Home Administrator that the necessary background checks were not completed as required by the facility's policy.
Failure to Notify Physician of Significant Change in Condition
Penalty
Summary
The facility failed to consult with a physician regarding a significant change in condition for a resident diagnosed with a urinary tract infection (UTI). The resident, who had a history of benign prostatic hyperplasia, urinary retention, and malignant neoplasm of the right kidney, exhibited a fever of 101.6°F. A urinalysis culture and sensitivity test confirmed the presence of Escherichia coli, indicating a UTI. Despite this, the facility did not promptly notify the resident's urologist to obtain necessary antibiotic orders. The facility's policy required timely provider notification upon a change in condition, but there was a delay in communication with the urology department. The resident's urinalysis results were sent to the urologist, but there was no follow-up call to ensure the results were received and acted upon. This lack of communication resulted in a delay of five days before the resident received the appropriate antibiotic treatment. The delay in treatment was acknowledged by the facility's Infection Preventionist/Assistant Director of Nursing, who confirmed that there was no documented attempt to contact the urologist between the preliminary results and the receipt of the antibiotic order. This inaction was contrary to the facility's policy and expectations for immediate treatment of symptomatic conditions with confirmed lab results.
Failure to Conduct Comprehensive Assessment for Resident's Change in Condition
Penalty
Summary
The facility failed to ensure a comprehensive assessment was completed for a resident (R21) who experienced a change in condition. R21, who has a medical history including bipolar disorder, diabetes mellitus, history of TIA, seizure disorder, obesity, and sleep apnea, had an episode of unresponsiveness. Despite the facility's standard practice of using Interact II, which requires immediate physician notification for sudden changes in consciousness or speech, the facility did not complete a full assessment or notify the physician. This oversight occurred even though R21 had a history of TIAs and seizure disorder, which necessitates careful monitoring and prompt medical intervention. Additionally, R21 experienced difficulty finding words and exhibited altered speech, yet the facility again failed to conduct a comprehensive assessment or notify the physician. Interviews with facility staff, including an LPN and the DON, revealed that the staff recognized the need for immediate physician notification and a full assessment in such situations. However, the DON initially dismissed these symptoms as normal behavior for R21, later acknowledging that an assessment and physician notification should have been conducted to determine if the symptoms were indicative of a medical issue.
CNA Worked Without Wisconsin Registry Listing
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) was listed on the Wisconsin Nurse Aide Registry before starting work. CNA T, one of five staff members reviewed, was hired on June 3, 2024, and began working with residents on June 15, 2024, without being on the Wisconsin registry. The Nursing Home Administrator (NHA) provided a certificate from the Iowa CNA registry but did not have a Wisconsin registry listing for CNA T. The NHA believed CNA T could work while their application for the Wisconsin registry was pending, which is against the Wisconsin Nurse Aide Training and Registry requirements. As of August 14, 2024, CNA T was still not listed on the Wisconsin registry.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, resulting in a rate of 10.26% during a survey. This deficiency was observed in the administration of medications to three residents. For one resident, a timing error occurred when Humalog Injection Solution, prescribed to be administered with meals, was given 25 minutes before the meal arrived. The registered nurse acknowledged the error when questioned by the surveyor. Another resident experienced a dosing error when the registered nurse crushed an extended-release Metoprolol Succinate tablet, which should not be crushed. The nurse admitted to the mistake upon review with the surveyor. Additionally, a third resident did not receive the correct medication as prescribed. Instead of Sennosides-Docusate Sodium, the resident was given only Senna, and the prescribed Artificial Tear Solution was unavailable for administration, leading to an omission error. The Director of Nursing confirmed the expectations for medication administration, including adherence to physician orders and the availability of medications. The surveyor's findings highlighted the facility's failure to ensure medications were administered correctly, as per the physician's orders, and that medications were available for administration, contributing to the high medication error rate.
Significant Medication Error Due to Improper Administration
Penalty
Summary
The facility failed to ensure that residents are free from significant medication errors, as evidenced by the actions of a registered nurse (RN D) who crushed and administered Metoprolol Succinate Extended Release to a resident (R31). The facility's policy on medication administration clearly states that extended-release medications should not be crushed, and an alternative should be sought if necessary. Despite this, RN D was observed by a surveyor crushing the extended-release medication and administering it to the resident, which is against the prescribed physician orders. Upon inquiry, RN D acknowledged that extended-release medications should not be crushed and admitted to the error. The Director of Nursing (DON B) confirmed that staff are expected to follow physician orders and that it is not acceptable to crush Metoprolol extended-release tablets without a specific physician order. The DON was made aware of the significant medication error after the surveyor's discussion with RN D, highlighting a lapse in adherence to medication administration protocols.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hazel Green
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunnycrest Manor | 6.1 mi | ★★★★★ | 6 | 0 |
| Bethany Home | 6.3 mi | ★★★★★ | 0 | 0 |
| Stonehill Care Center | 6.7 mi | ★★★★★ | 0 | 0 |
| Mount Carmel Bluffs | 6.8 mi | ★★★★★ | 3 | 0 |
| Harmony Dubuque | 7.2 mi | ★★★★★ | 10 | 0 |
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