01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-06-25 | 7 | 2026-06-25 | 0 |
| Cycle 2 | 2025-05-05 | 3 | 2025-05-05 | 3 |
| Cycle 3 | 2024-02-08 | 4 | 2024-02-08 | 1 |
CMS CCN 6761702026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
St Dominic Village Rehabilitation And Nursing Cent
2409 E Holcombe Blvd · Houston, TX 77021 · Harris County
Certified beds158CMS provider file
Recent citation rows18current CMS citation release
Penalty rows5current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
18 rows in the current release
1 rows carry G–L scope/severity codes; 0 carry J–L. 2 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-06-25 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has no plan of correction2026-06-25 · HEALTHF0759Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has no plan of correction2026-06-25 · HEALTHF0851Severity F · widespread; potential for more than minimal harm
Administration Deficiencies
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Correction field: Deficient, Provider has no plan of correction2026-06-25 · HEALTHF0883Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Correction field: Deficient, Provider has no plan of correction2026-06-25 · HEALTHF0887Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has no plan of correction2026-04-30 · HEALTHF0602Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from the wrongful use of the resident's belongings or money.
Correction field: Deficient, Provider has date of correction · 2026-05-22 · complaint2025-12-17 · HEALTHF0656Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-01-12 · complaint2025-05-05 · HEALTHF0600Severity G · isolated actual harm
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.
Correction field: Deficient, Provider has date of correction · 2025-05-27 · complaint2025-05-05 · HEALTHF0656Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-05-27 · complaint2025-05-05 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-05-27 · complaint2025-05-05 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2025-05-262025-05-05 · FIREK0353Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-05-262025-05-05 · FIREK0511Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2025-05-262024-02-08 · HEALTHF0645Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Correction field: Deficient, Provider has date of correction · 2024-03-042024-02-08 · HEALTHF0692Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2024-03-062024-02-08 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2024-03-062024-02-08 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2024-03-062024-02-08 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2024-02-2603 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-05-05 | Fine | $12,470 | 0 |
| 2024-01-08 | Fine | $4,938 | 0 |
| 2024-01-02 | Fine | $4,587 | 0 |
| 2023-12-11 | Fine | $11,645 | 0 |
| 2023-11-06 | Fine | $8,391 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- ST. DOMINIC VILLAGEOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 05/01/1999
- DELLORO, ITALOIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 10/01/2021
- LEMMING, SANDRAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 07/01/2022
- BADUM, JAMESIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 06/01/2023
- BROOKS, RICHARDIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 06/01/2021
- GIBLER, LINDAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 10/01/2022
- HOTZE, BRUCEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/01/2022
- IDSTEIN, HUGHIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2021
- LAYNE, PAULIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 10/01/2022
- MAKULSKI, MARTINIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2024
- MAZZARA, BENIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 10/01/2024
- MICHALEC, ROSEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 10/01/2024
- NARCISSE, VICTORIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2022
- PARSLEY, KATHERINEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 12/01/2024
- PELZ, LOUIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2022
- SCHRIBER, LYNNIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2024
- SEPE, FAITHIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 10/01/2018
- TSCHIRCH, POLDIIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2021
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours—per resident day
RN hours—per resident day
Weekend nurse hours—per resident day
Staff turnover—%CMS reported field
06 / LOCAL RECORDS
Open the Houston ledger →Other published facilities nearby
Afton Oaks Nursing And Rehabilitation Center169 beds · CMS overall 1/544 citation rowsAshford Gardens202 beds · CMS overall 2/537 citation rowsAvir At Arden Wood174 beds · CMS overall 2/550 citation rowsAvir At Courtyard120 beds · CMS overall 4/526 citation rowsAvir At Golfcrest200 beds · CMS overall 2/532 citation rowsAvir At Houston148 beds · CMS overall 1/551 citation rowsAvir At Orem120 beds · CMS overall 4/537 citation rowsAvir At Veterans Memorial120 beds · CMS overall 1/538 citation rows