St. Anne's Salvatorian Campus

Penalties

• Mar 26, 2026 — Fine ($119,850)
• Mar 26, 2026 — Payment Denial · payment denial 21 days
• Jan 7, 2026 — Fine ($19,115)
• Jan 7, 2026 — Payment Denial · payment denial 23 days
• Nov 14, 2024 — Payment Denial · payment denial 112 days
• Nov 14, 2024 — Fine ($204,523)

Inspection findings

1. Mar 26, 2026 Health · 12 findings
   • Not serious Scope/severity D

     F0578 Resident Rights Deficiencies

     Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

     Corrected May 13, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0605 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

     Corrected Apr 20, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0628 Resident Rights Deficiencies

     Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

     Corrected Apr 20, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Apr 20, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Apr 20, 2026 · CMS health inspection

   • Serious Scope/severity G

     F0686 Quality of Life and Care Deficiencies

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

     Corrected May 13, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 20, 2026 · 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 Apr 20, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0887 Infection Control Deficiencies

     Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

     Corrected Apr 20, 2026 · CMS health inspection

   • Not serious Scope/severity E

     K0293 Egress Deficiencies

     Have properly located and lighted "Exit" signs.

     Corrected Apr 13, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Apr 13, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Apr 17, 2026 · CMS fire safety

2. Jan 7, 2026 Health · 2 findings
   • Serious Scope/severity G 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 2, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0757 Pharmacy Service Deficiencies

     Ensure each resident’s drug regimen must be free from unnecessary drugs.

     Corrected Feb 2, 2026 · CMS health inspection

3. Jun 13, 2025 Health · 3 findings
   • 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 Jul 11, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Jul 11, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jul 11, 2025 · CMS health inspection

4. Mar 5, 2025 Health · 1 finding
   • Serious Scope/severity G Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Apr 15, 2025 · CMS health inspection

5. Nov 14, 2024 Fire Safety · 26 findings
   • Not serious Scope/severity F

     E0018 Emergency Preparedness Deficiencies

     Establish procedures for tracking staff and patients during an emergency.

     Corrected Dec 19, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0035 Emergency Preparedness Deficiencies

     Provide family notifications of emergency plan.

     Corrected Dec 19, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Dec 19, 2024 · CMS fire safety

   • Not serious Scope/severity D

     F0554 Resident Rights Deficiencies

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

     Corrected Dec 19, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Dec 19, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0578 Resident Rights Deficiencies

     Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

     Corrected Dec 19, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Dec 19, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0623 Resident Rights Deficiencies

     Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

     Corrected Dec 19, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Dec 19, 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 Apr 15, 2025 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0686 Quality of Life and Care Deficiencies

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

     Corrected Apr 15, 2025 · 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 Apr 15, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected Dec 19, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0698 Quality of Life and Care Deficiencies

     Provide safe, appropriate dialysis care/services for a resident who requires such services.

     Corrected Dec 19, 2024 · CMS health inspection

   • Not serious Scope/severity D

     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 Dec 19, 2024 · CMS health inspection

   • Not serious Scope/severity E 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 Dec 19, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0745 Quality of Life and Care Deficiencies

     Provide medically-related social services to help each resident achieve the highest possible quality of life.

     Corrected Dec 19, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Dec 19, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Dec 19, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0838 Administration Deficiencies

     Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

     Corrected Dec 19, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0849 Administration Deficiencies

     Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

     Corrected Dec 19, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 15, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0881 Infection Control Deficiencies

     Implement a program that monitors antibiotic use.

     Corrected Dec 19, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0132 Construction Deficiencies

     Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.

     Corrected Dec 19, 2024 · CMS fire safety

   • Not serious Scope/severity C

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected Dec 19, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0781 Miscellaneous Deficiencies

     Have restrictions on the use of portable space heaters.

     Corrected Dec 19, 2024 · CMS fire safety

6. Aug 7, 2024 Health · 2 findings
   • 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 Aug 24, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Aug 24, 2024 · CMS health inspection

7. Aug 17, 2023 Health · 36 findings
   • Not serious Scope/severity D Complaint

     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 13, 2023 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0584 Resident Rights Deficiencies

     Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

     Corrected Sep 13, 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 Sep 13, 2023 · CMS health inspection

   • Serious Scope/severity J 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 Sep 13, 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 Sep 13, 2023 · CMS health inspection

   • Not serious Scope/severity B

     F0623 Resident Rights Deficiencies

     Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

     Corrected Sep 13, 2023 · CMS health inspection

   • Not serious Scope/severity B

     F0625 Resident Rights Deficiencies

     Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

     Corrected Sep 13, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0655 Resident Assessment and Care Planning Deficiencies

     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

     Corrected Sep 13, 2023 · CMS health inspection

   • Not serious Scope/severity E

     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 Sep 13, 2023 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Sep 13, 2023 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Sep 13, 2023 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0686 Quality of Life and Care Deficiencies

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

     Corrected Sep 13, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0687 Quality of Life and Care Deficiencies

     Provide appropriate foot care.

     Corrected Sep 13, 2023 · CMS health inspection

   • Not serious Scope/severity E 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 Sep 13, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected Sep 13, 2023 · CMS health inspection

   • Not serious Scope/severity D

     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 Sep 13, 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 Sep 13, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0727 Nursing and Physician Services Deficiencies

     Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

     Corrected Sep 13, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0745 Quality of Life and Care Deficiencies

     Provide medically-related social services to help each resident achieve the highest possible quality of life.

     Corrected Sep 13, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0756 Pharmacy Service Deficiencies

     Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

     Corrected Sep 13, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0757 Pharmacy Service Deficiencies

     Ensure each resident’s drug regimen must be free from unnecessary drugs.

     Corrected Sep 13, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0758 Pharmacy Service Deficiencies

     Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

     Corrected Sep 13, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Sep 13, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Sep 13, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0773 Administration Deficiencies

     Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

     Corrected Sep 13, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Sep 13, 2023 · 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 13, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0909 Environmental Deficiencies

     Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

     Corrected Sep 13, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0941 Administration Deficiencies

     Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

     Corrected Sep 13, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0949 Administration Deficiencies

     Provide behavior health training consistent with the requirements and as determined by a facility assessment.

     Corrected Sep 13, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0132 Construction Deficiencies

     Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.

     Corrected Aug 25, 2023 · CMS fire safety

   • 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 Aug 25, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Aug 21, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Aug 25, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Aug 21, 2023 · CMS fire safety

   • Not serious Scope/severity C

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Aug 22, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• DETTMAN, SCOTT — corporate director, NOT APPLICABLE, since 01/04/2022
• FISCHER, TODD — corporate director, NOT APPLICABLE, since 01/04/2022
• HEROUX, STEVEN — corporate director, NOT APPLICABLE, since 08/01/2024
• KOHLHOFF, KEVIN — corporate director, NOT APPLICABLE, since 09/01/2023
• KONKOL, DENNIS — corporate director, NOT APPLICABLE, since 10/01/2024
• LIPKE, TESLA — adp of the snf, NOT APPLICABLE, since 04/24/2025
• LIPKE, TESLA — operational/managerial control, NOT APPLICABLE, since 04/16/2025
• MARKS, JULIE — corporate officer, NOT APPLICABLE, since 06/09/2025
• MARKS, JULIE — operational/managerial control, NOT APPLICABLE, since 06/09/2025
• MARKS, JULIE — adp of the snf, NOT APPLICABLE, since 06/09/2025
• MAUTHE, MATTHEW — adp of the snf, NOT APPLICABLE, since 01/04/2022
• MAUTHE, MATTHEW — corporate officer, NOT APPLICABLE, since 01/04/2022
• MAUTHE, MATTHEW — operational/managerial control, NOT APPLICABLE, since 01/04/2022
• MEIDENBAUER, ROBERT — corporate director, NOT APPLICABLE, since 01/04/2022
• SIDHU, SARFRAZ — operational/managerial control, NOT APPLICABLE, since 07/02/2021
• SIDHU, SARFRAZ — adp of the snf, NOT APPLICABLE, since 07/02/2021
• VAN DER LINDEN, KATIE — corporate director, NOT APPLICABLE, since 01/04/2022
• WAGNER, LYNNE — corporate director, NOT APPLICABLE, since 10/01/2024
• ILLUMINUS INC — adp of the snf, NOT APPLICABLE, since 04/24/2025
• ILLUMINUS INC — operational/managerial control, NOT APPLICABLE, since 01/04/2022
• MARQUARDT VILLAGE INC — 5% or greater direct ownership interest, 100%, since 01/04/2022
• MARQUARDT VILLAGE INC — operational/managerial control, NOT APPLICABLE, since 01/04/2022