Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Soldiers Grove Health Services during CMS and state inspections, most recent first.
A resident did not receive care and treatment in accordance with physician orders and their stated preferences and goals, as observed and documented by surveyors.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, as observed by surveyors during their assessment.
The facility's high temperature dishwasher failed to consistently reach required sanitizing temperatures, as documented in temperature logs over multiple days. Staff did not notify the Dietary Manager or take corrective actions when temperatures were insufficient, resulting in unsanitary dishware and potentially affecting all residents.
The facility did not maintain a comprehensive infection surveillance line list, as required by its own policies, resulting in incomplete tracking of residents' symptoms, lab results, and infection status. Instead, information was scattered across multiple lists and the EHR, and interviews with the IP and DON confirmed the lack of a single, consolidated tracking system. This deficiency affected all residents in the facility.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal, and failed to establish or implement a grievance policy or promptly resolve complaints as required.
Failure to provide PASRR specialized services: A resident with severe ID and cerebral palsy had a PASRR Level I that led to a Level II, and the Level II stated the resident had an IDD and SMI and needed specialized services. The facility had confusion over conflicting Level II documents, could not provide documentation supporting its interpretation, and staff acknowledged the resident was not receiving specialized services; activities and therapy were described as general services available to all residents.
A resident with left-sided weakness following a stroke, who was assessed as needing partial to moderate assistance with dressing, did not have these needs reflected in the care plan. Despite OT recommendations and staff awareness of the resident's limitations, the care plan failed to specify the required assistance for dressing, resulting in the resident not receiving appropriate help.
A resident did not receive sufficient food and fluids to maintain their health, as required. The facility failed to ensure the necessary provision of nutrition and hydration.
The facility did not have a program in place to monitor antibiotic use, lacking a system to track or evaluate antibiotic administration among residents.
A resident with lung and bone cancer experienced declining oxygen saturation levels, falling below 90% on multiple occasions. Despite facility policy requiring immediate physician notification for such changes, staff failed to update the physician and increased the resident's oxygen above the ordered 3L/min without authorization. Interviews with facility staff confirmed non-compliance with standard practices, resulting in inadequate care for the resident's condition.
A facility failed to include a resident's history of making false allegations in their care plan, despite the resident's severe cognitive impairment and history of false abuse claims. The DON acknowledged the oversight, which was contrary to the facility's policy requiring comprehensive care plans to address all resident needs.
The facility failed to maintain sanitary conditions and proper hand hygiene in food service. Opened and undated food containers were observed, and a cook was seen eating in the kitchen and handling food without washing hands or changing gloves appropriately. These actions have the potential to affect all 35 residents in the facility.
The facility failed to ensure complete and accurate staffing data submission from July to December 2023, affecting all 35 residents. The issue was due to reporting errors related to agency staff hours, which were not correctly locked in the time card system, leading to incomplete PBJ reports.
A resident with Alzheimer's and mobility issues experienced multiple falls due to malfunctioning alarms and wheelchair brakes. The facility failed to investigate the causes of these malfunctions or discuss them in team meetings, despite having policies in place for fall prevention and alarm management.
A resident with multiple diagnoses, including neurogenic bladder and diabetes, did not receive proper bowel continence care as per their care plan. Staff failed to offer scheduled toileting and relied on physical cues, leading to inconsistent care. Observations and interviews confirmed that the care plan was not followed, and the resident was not toileted as required.
The facility failed to develop a care plan for a resident's nicotine use, despite the resident being found with multiple vape pens and a Dab pen. The resident's nicotine use was managed through a lock box system, but the care plan was not updated to reflect this, leading to a deficiency noted by the surveyor.
The facility failed to assess a resident's ability to use e-cigarettes after discovering the resident's nicotine use, leading to a deficiency in maintaining a safe environment. Staff were unaware of the resident's smoking habits, and no updated nicotine safety assessment was completed after the incident.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of records, which showed that care provided did not align with the documented orders or the expressed wishes and care goals of the resident involved.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. The lack of proper supervision and the presence of hazards in the area were directly observed by surveyors during their assessment.
Dishwasher Temperatures Not Maintained for Safe Food Service
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for food preparation, storage, and distribution, as required by professional standards. Specifically, the high temperature dishwasher used to clean and sanitize dishware did not consistently reach the required rinse temperature of 180 degrees Fahrenheit or the non-regressing thermometer reading of 160 degrees Fahrenheit. The dish machine log for July 2025 showed that the rinse temperature was below 180 degrees Fahrenheit on seven occasions and the non-regressing thermometer did not reach 160 degrees Fahrenheit on nineteen occasions between July 1 and July 17, 2025. These temperature deficiencies were documented during routine logging at breakfast, lunch, and dinner. Despite these recorded temperature failures, the Dietary Manager was not notified of the issues, and staff did not take corrective actions such as re-running the dishwasher or escalating the problem when repeated attempts failed to reach the necessary temperatures. The facility's policy required staff to be knowledgeable about proper dishwashing techniques and to maintain temperature logs in accordance with manufacturer recommendations, but these procedures were not followed. As a result, all 34 residents in the facility were potentially affected by the failure to properly sanitize dishware.
Failure to Maintain Comprehensive Infection Surveillance Line List
Penalty
Summary
The facility failed to establish and implement an effective infection prevention and control program as required by policy. Specifically, the facility did not maintain a comprehensive line list to monitor all residents for signs and symptoms of actual or potential infections. The documentation provided for the months of April, May, and June only included an infection control log with resident names, antibiotics ordered, and start and end dates, but lacked critical information such as residents' symptoms, lab results, imaging results, and whether residents met criteria for antibiotic use. Interviews with the Infection Preventionist and the Director of Nursing confirmed that there was no single, consolidated list tracking these details, and that information was instead dispersed across multiple lists and within the electronic health record. The facility's own policies require the Infection Preventionist to lead surveillance activities, maintain documentation of incidents and findings, and report surveillance outcomes to the Quality Assessment and Assurance Committee and public health authorities as needed. However, the absence of a comprehensive surveillance line list meant that the facility was not adequately tracking or trending residents' symptoms or potential infections. This deficiency had the potential to affect all 34 residents in the facility, as there was no systematic method in place to identify, report, investigate, or control infections and communicable diseases among residents, staff, volunteers, or others providing services.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. The facility did not establish or implement a grievance policy and did not make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's lack of appropriate procedures and actions to address resident complaints.
Failure to Provide PASRR Specialized Services
Penalty
Summary
The facility did not follow through with the appropriate steps of the PASRR process for one resident with severe intellectual disabilities and cerebral palsy. The resident’s record showed a PASRR Level I screen completed on 9/27/22 that was indicative of a PASRR Level II, and the PASRR Level II dated 10/05/22 stated that the resident had both an intellectual developmental disability and a serious mental illness and needed specialized services to address developmental disability needs. The resident’s care plan also identified a focus on specialized services due to severe intellectual disability and cerebral palsy. During interview, the Social Services Director stated there was confusion because the facility received one PASRR Level II stating the resident needed specialized services and another PASRR Level II stating she did not require specialized services, both dated 10/05/22. The Social Services Director said the facility had been told it was up to them whether to provide the specialized services, but no documentation of that was provided to the surveyor. The Social Services Director also stated the facility care planned the resident as needing specialized services, but could not identify documentation showing what the facility relied on to interpret the Level II. The Social Services Director stated the facility was using therapy at one time and activities, but also acknowledged those services were available to all residents. At the time of interview, the Social Services Director said she did not think the resident had any services in place right now and there were no follow-up renewals. The Activity Director described providing one-to-one sessions two to three times per week with sorting, greeting cards, exercise class, music activities, and small group participation, while the DON stated activities and therapy were not specialized services. The facility did not provide the resident with specialized services per the PASRR Level II recommendations.
Failure to Address Dressing Assistance in Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to develop a comprehensive care plan that addressed the specific assistance required for dressing for one resident. The resident, who had a history of hemiplegia and hemiparesis following a stroke, pain, major depressive disorder, and hypertension, was assessed as cognitively intact and required partial to moderate assistance with lower body dressing and personal hygiene according to the Minimum Data Set (MDS) and occupational therapy (OT) discharge summary. However, the resident's care plan only addressed personal hygiene and did not specify the type or amount of assistance needed for dressing. Interviews with the resident revealed that he was not receiving the help he needed from staff, and a CNA confirmed that the care plan did not address the resident's dressing needs. The Director of Nursing stated that therapy recommendations are supposed to be communicated to nursing staff for care plan updates, but was unaware of the OT's recommendations for this resident. The lack of inclusion of the OT's recommendations and the failure to update the care plan resulted in the resident's dressing needs not being properly addressed.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement a program that monitors antibiotic use. There is no evidence provided that the facility had a system in place to track, review, or evaluate the use of antibiotics among residents. The absence of such a program was identified during the survey, indicating a lack of oversight regarding antibiotic administration and stewardship within the facility. No specific residents or staff were mentioned in relation to this deficiency, and no details about individual medical histories or conditions were provided.
Failure to Notify Physician of Resident's Declining Oxygen Levels
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a need to alter treatment, specifically for a resident with a change in condition. The resident, who was diagnosed with lung cancer, bone cancer, and respiratory failure, had oxygen saturation levels that fell below the prescribed parameters on several occasions. Despite these changes, the facility staff did not update the physician or obtain orders to increase the resident's oxygen levels, which were increased above the ordered 3 liters per minute without proper authorization. The facility's policy requires immediate notification of the physician when there is a significant change in a resident's condition, such as oxygen saturation levels dropping below 90%. However, the staff failed to adhere to this policy, as evidenced by the resident's documented oxygen saturation levels, which frequently fell below the threshold without physician notification. The facility's Director of Nursing and other staff members confirmed that the standard practice was not followed, acknowledging that the physician should have been notified and that oxygen should not have been increased without an order. Interviews with facility staff, including the Director of Nursing, Registered Nurses, and the Assistant Director of Nursing, revealed a lack of compliance with the facility's standard practices and guidelines. The staff admitted that increasing oxygen levels without a physician's order was against protocol and that the physician should have been informed of the resident's declining oxygen saturation levels. This oversight resulted in a failure to provide appropriate care and consultation for the resident's changing condition.
Failure to Address Resident's History of False Allegations in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive resident-centered care plan for a resident with a history of making false allegations. This deficiency was identified during a survey where it was noted that the resident's care plan did not include any interventions or strategies to address this behavior, despite the facility's policy requiring care plans to be consistent with resident rights and include measurable objectives and timeframes to meet the resident's needs. The resident, who has severe cognitive impairment and a history of stroke, vascular dementia, and anxiety, was involved in an incident where they falsely accused a male nurse of causing bruises. The Director of Nursing (DON) acknowledged awareness of the resident's history of making false allegations since admission but confirmed that this was not included in the resident's comprehensive care plan. The facility's self-report and subsequent investigation, which involved law enforcement and the resident's guardian, confirmed the resident's history of false allegations. Despite this, the care plan lacked specific interventions to manage or mitigate the impact of these false allegations, which is a requirement under the facility's policy for comprehensive care planning.
Failure to Maintain Sanitary Conditions and Proper Hand Hygiene in Food Service
Penalty
Summary
The facility failed to distribute food under sanitary conditions, did not utilize proper glove use, and handled food without proper hand hygiene. During an initial kitchen tour, the surveyor observed opened and undated containers of various food items, including milk and dressing, which were not labeled with the date opened or the date of discard. Additionally, a cook was observed eating and drinking in the kitchen area and then proceeding to prepare and serve food without conducting hand hygiene. The cook touched various surfaces and food items without washing hands or changing gloves appropriately, which is against the facility's infection control policy. The surveyor observed multiple instances where the cook did not follow proper hand hygiene protocols, such as touching their face, handling utensils, and serving food without washing hands. The cook also placed dirty dishes in the sink and cleaned the prep area without conducting hand hygiene before serving lunch. Interviews with the Certified Dietary Manager and the cook confirmed that staff are not supposed to eat in the kitchen area and are expected to perform hand hygiene after touching contaminated items, before and after glove use, and before serving food. These actions have the potential to affect all 35 residents in the facility.
Incomplete and Inaccurate Staffing Data Submission
Penalty
Summary
The facility did not ensure that the mandatory staffing data submitted from July 1, 2023, to December 31, 2023, was complete, accurate, and auditable. This affected all 35 residents residing in the facility. The Payroll Based Journal (PBJ) Staffing Data Reports indicated excessively low weekend staffing and a one-star staffing rating during this period. However, a review of the facility's time sheets and daily schedule sheets for the weekends in question showed adequate staffing, and interviews with family members and residents did not reveal any complaints or concerns regarding weekend staffing. The issue was identified as a reporting error related to the use of agency staff to fill required shifts on weekends. The facility's time card system did not correctly lock in the agency staff hours, resulting in incomplete data being pulled into the PBJ reports. This error was recognized by the corporation, which then provided education to administrators on the proper way to submit staff information. The training occurred on March 18, 2024, and the facility implemented three different monitoring systems to reduce the chance of future errors.
Failure to Ensure Adequate Supervision and Functioning of Assistance Devices
Penalty
Summary
The facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for one resident. The resident, who has Alzheimer's disease, unspecified dementia, difficulty in walking, and muscle weakness, had multiple falls that were not properly investigated. The facility's policies on fall prevention and resident alarms were not followed, as evidenced by the lack of investigation into why alarms were not functioning or why wheelchair brakes were not locked during the incidents. The resident's care plan included several interventions to prevent falls, but these were not effectively monitored or implemented. On two separate occasions, the resident experienced unwitnessed falls. In the first incident, the resident was found on the bathroom floor with the wheelchair alarm not sounding and brakes not locked. In the second incident, the resident was found on the floor next to the bed with the bed alarm unplugged. Despite these occurrences, no thorough investigation was conducted to determine the root cause of the alarm failures or the malfunctioning of the wheelchair brakes. The Director of Nursing confirmed that these issues were not discussed in Interdisciplinary team meetings or Quality Assurance meetings, and staff did not investigate or address the malfunctioning devices as expected.
Failure to Ensure Proper Bowel Continence Care
Penalty
Summary
The facility did not ensure proper assessments and interventions for bowel continence for a resident with a neurogenic bladder, acute pyelonephritis, diabetes mellitus type 2, and mild intellectual disability. The resident's care plan indicated the need for regular toileting to maintain bowel continence and prevent falls. However, observations revealed that staff did not consistently follow the care plan, failing to offer toileting at scheduled times and relying instead on physical cues from the resident, which were not always reliable or timely identified. The resident's Minimum Data Set (MDS) and care plan indicated frequent bowel incontinence, yet the bowel assessments lacked detailed descriptions of the type of incontinence or contributing factors. There were no individualized interventions to assist the resident in maintaining bowel continence. The resident's care plan specified the use of a Hoyer lift and an ez-stand for toileting, but staff did not consistently use the ez-stand for toileting as required. Observations on a specific day showed that the resident was not offered toileting throughout the day, despite being in a Broda chair and exhibiting signs of needing to use the bathroom. Interviews with CNAs revealed that they did not follow the care plan's scheduled toileting times, instead waiting for physical cues from the resident. The Director of Nursing confirmed that CNAs should follow the care plan and Kardex to maintain the resident's bowel continence and prevent falls, which was not being done consistently.
Failure to Develop Care Plan for Nicotine Use
Penalty
Summary
The facility did not ensure a care plan was developed for nicotine use for one resident. The facility's policy requires a comprehensive person-centered care plan to be developed within seven days after the completion of the comprehensive MDS assessment, including measurable objectives and timeframes to meet the resident's needs. However, a review of the resident's progress notes revealed an incident where the resident was found with multiple vape pens and a Dab pen in their bed. Despite the resident's understanding and compliance with the facility's rules regarding the use of tobacco products, there was no care plan addressing the resident's nicotine use. Interviews with the resident, CNA, RNs, and the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the resident's nicotine use was known and managed through a lock box system. However, the care plan was not updated to reflect this. The DON admitted that they expected the MDS coordinator to update the care plans, which was not done in this instance. This oversight led to the deficiency noted by the surveyor.
Failure to Assess Resident's Nicotine Use
Penalty
Summary
The facility did not ensure that the resident environment remained as free of accident hazards as possible by failing to assess a resident's ability to use e-cigarettes after determining that the resident used nicotine products. This deficiency was identified for one resident who was found with multiple vape pens and a Dab pen in their bed after an incident where the resident was incontinent of stool. The facility's policy required a nicotine assessment upon admission, quarterly, annually, and as needed, but the most recent assessment for this resident was completed before the incident and did not reflect the resident's current nicotine use. Interviews with the resident and staff revealed that the resident was aware of the designated smoking areas and the new rule that their smoking materials were to be locked at the nurse's station. However, the staff, including a CNA and RNs, were not fully aware of the resident's smoking habits, and no updated nicotine safety assessment was completed after the incident. The Director of Nursing confirmed that an assessment should have been completed but was not done, indicating a lapse in following the facility's policy and ensuring resident safety.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 56 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Soldiers Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vernon Manor | 14.2 mi | ★★★★★ | 11 | 0 |
| Care And Rehab - Boscobel | 18 mi | ★★★★★ | 0 | 0 |
| Schmitt Woodland Hills | 18.8 mi | ★★★★★ | 10 | 0 |
| Norseland Nursing Home | 19.2 mi | ★★★★★ | 0 | 0 |
| Pine Valley Community Village | 20.7 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.