St Dominic Villa

Penalties

• Aug 15, 2024 — Fine ($49,823)
• Aug 15, 2024 — Payment Denial · payment denial 49 days
• Oct 6, 2023 — Fine ($79,644)
• Oct 6, 2023 — Payment Denial · payment denial 119 days

Inspection findings

1. Dec 22, 2025 Health · 9 findings
   • Serious Scope/severity J

     F0700 Quality of Life and Care Deficiencies

     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 Jan 23, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0740 Quality of Life and Care Deficiencies

     Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

     Corrected Jan 23, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jan 23, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jan 23, 2026 · CMS health inspection

   • Not serious Scope/severity D

     K0223 Egress Deficiencies

     Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

     Corrected Jan 22, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Jan 22, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Jan 22, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0912 Gas, Vacuum, and Electrical Systems Deficiencies

     Have power receptacles that are properly grounded.

     Corrected Jan 22, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Jan 22, 2026 · CMS fire safety

2. Aug 15, 2024 Fire Safety · 16 findings
   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Sep 16, 2024 · CMS fire safety

   • Not serious Scope/severity D

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Sep 16, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected Sep 16, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Sep 16, 2024 · CMS health inspection

   • Serious Scope/severity J

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Sep 16, 2024 · CMS health inspection

   • Serious Scope/severity G

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Nov 1, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0729 Nursing and Physician Services Deficiencies

     Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.

     Corrected Sep 16, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Sep 16, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Sep 16, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Sep 16, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Sep 16, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0882 Infection Control Deficiencies

     Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

     Corrected Sep 16, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0223 Egress Deficiencies

     Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

     Corrected Sep 16, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Sep 16, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Sep 16, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Sep 16, 2024 · CMS fire safety

3. Feb 12, 2024 Health · 3 findings
   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Mar 1, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0711 Nursing and Physician Services Deficiencies

     Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

     Corrected Mar 1, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0740 Quality of Life and Care Deficiencies

     Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

     Corrected Mar 1, 2024 · CMS health inspection

4. Nov 30, 2023 Health · 1 finding
   • Serious Scope/severity G Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Feb 9, 2024 · CMS health inspection

5. Oct 6, 2023 Health · 10 findings
   • Not serious Scope/severity D Complaint

     F0585 Resident Rights Deficiencies

     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 Oct 30, 2023 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Oct 30, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Oct 30, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Oct 30, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Oct 30, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Oct 30, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Oct 30, 2023 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0725 Nursing and Physician Services Deficiencies

     Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

     Corrected Oct 30, 2023 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0868 Administration Deficiencies

     Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

     Corrected Oct 30, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Oct 30, 2023 · CMS health inspection

6. Apr 19, 2023 Fire Safety · 12 findings
   • Not serious Scope/severity F

     E0006 Emergency Preparedness Deficiencies

     Conduct risk assessment and an All-Hazards approach.

     Corrected May 19, 2023 · CMS fire safety

   • Not serious Scope/severity D

     F0554 Resident Rights Deficiencies

     Allow residents to self-administer drugs if determined clinically appropriate.

     Corrected May 19, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected May 19, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected May 19, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected May 19, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 19, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     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 May 19, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0223 Egress Deficiencies

     Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

     Corrected May 19, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected May 19, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0347 Smoke Deficiencies

     Properly provide smoke detection systems in areas open to corridors.

     Corrected May 19, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected May 19, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected May 19, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• BRUNER, JOSHUA — adp of the snf, NOT APPLICABLE, since 04/25/2025
• BRUNER, JOSHUA — operational/managerial control, NOT APPLICABLE, since 05/06/2024
• DROESZLER, ZACHARY — operational/managerial control, NOT APPLICABLE, since 08/01/2024
• DROESZLER, ZACHARY — adp of the snf, NOT APPLICABLE, since 08/01/2024
• MARKS, JULIE — operational/managerial control, NOT APPLICABLE, since 06/09/2025
• MARKS, JULIE — corporate officer, NOT APPLICABLE, since 06/09/2025
• MARKS, JULIE — adp of the snf, NOT APPLICABLE, since 06/09/2025
• MAUTHE, MATTHEW — operational/managerial control, NOT APPLICABLE, since 06/10/2020
• MAUTHE, MATTHEW — adp of the snf, NOT APPLICABLE, since 06/10/2020
• MAUTHE, MATTHEW — corporate director, NOT APPLICABLE, since 06/10/2020
• MAUTHE, MATTHEW — corporate officer, NOT APPLICABLE, since 06/10/2020
• ROGERS, DOUG — corporate director, NOT APPLICABLE, since 12/01/2020
• ROSEMEYER, JOSEPH — corporate director, NOT APPLICABLE, since 11/01/2024
• SMITH, KENNETH — corporate director, NOT APPLICABLE, since 11/01/2024
• SOOKOCHOFF, JESSE — corporate director, NOT APPLICABLE, since 12/01/2020
• ILLUMINUS INC — adp of the snf, NOT APPLICABLE, since 10/17/2025
• ILLUMINUS INC — operational/managerial control, NOT APPLICABLE, since 06/10/2020
• SOUTHWEST HEALTH CENTER INC — 5% or greater direct ownership interest, since 06/10/2020
• SWR1 INC — 5% or greater direct ownership interest, since 06/10/2020
• THE HILLS AT CORTLAND RIDGE, INC. — direct ownership interest, NOT APPLICABLE, since 06/10/2020