Soldiers Grove Health Services

In the surveyor’s words

From the most serious findings on record at Soldiers Grove Health Services, in the surveyor’s own words.

• Actual harm, isolatedF684Jul 21, 2025

  Based on interview and record review, the facility did not ensure each resident receives the necessary care and services in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 13 sampled residents (R20) resulting in actual harm. R20 was self-transferring multiple times and on the eighth attempt, suffered an unwitnessed fall. The facility failed to provide an assessment completed by an RN (Registered Nurse) or with RN oversight at the time of the fall. The facility failed to notify the physician timely of the fall, failed to relay all of R20's symptoms to physician and DON B (Director of Nursing) at the time of the fall, and failed to notify physician of changes of condition following the fall. […]

• Actual harm, isolatedF689Jul 21, 2025

  Based on interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 1 residents (R20) reviewed for falls resulting in actual harm.R20 was self-transferring multiple times and on the eighth attempt, suffered an unwitnessed fall. The facility failed to provide temporary interventions to address the self-transferring. R20 was found to have a left acetabular (hip joint socket) fracture.This is evidenced by:Facility policy, titled Fall Prevention and Management Guidelines, reviewed and revised on 7/18/24, states in part; Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls or reduce… […]

• No harm, potential for more than minimal, widespreadF812Jul 21, 2025

  Number of residents sampled:34Number of residents cited:34Based on record review and interview, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 34 residents who reside in the facility.The facility's dishwasher was not reaching appropriate temperatures.Findings includeThe facility employs a high temperature dishwasher to clean and sanitize its dishware.The facility's policy, titled Warewashing, states, in part, All dishware, service ware, and utensils will be cleaned and sanitized after each use.the dining services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware.all dish machine water… […]

• No harm, potential for more than minimal, widespreadF880Jul 21, 2025

  Number of residents sampled:34Number of residents cited:34Based on interview and record review, the facility has not established 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. This has the potential to affect the census of 34 residents. The facility has not established a line list that reflects resident's symptoms, lab results, symptom onset date, and the type of infection a resident has. Evidenced by: The facility's policy titled Infection Surveillance dated 3/8/23 states in part .1. […]

• No harm, potential for more than minimal, widespreadF812May 9, 2024

  Based on observation and interview, the facility failed to distribute food under sanitary conditions, did not utilize proper glove use and handled food without proper hand hygiene. This has the potential to affect all 35 residents who reside in the facility. This is evidenced by: The facility policy and procedures for Healthcare Services Group entitled, Infection control overview & Policy, states in part, Implement hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination. […]