Soldiers Grove Health Services

Inspection findings

1. Jul 21, 2025 Fire Safety · 15 findings
   • Not serious Scope/severity F

     E0006 Emergency Preparedness Deficiencies

     Conduct risk assessment and an All-Hazards approach.

     Corrected Aug 18, 2025 · CMS fire safety

   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Aug 18, 2025 · CMS fire safety

   • Not serious Scope/severity D

     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 Aug 18, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Aug 18, 2025 · 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 Aug 18, 2025 · CMS health inspection

   • Serious Scope/severity G

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Aug 18, 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 Aug 18, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Aug 18, 2025 · 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 Aug 18, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Aug 18, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0881 Infection Control Deficiencies

     Implement a program that monitors antibiotic use.

     Corrected Aug 18, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0293 Egress Deficiencies

     Have properly located and lighted "Exit" signs.

     Corrected Aug 18, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0343 Smoke Deficiencies

     Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

     Corrected Aug 18, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0521 Services Deficiencies

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

     Corrected Aug 18, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0919 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the use of electrical equipment.

     Corrected Aug 18, 2025 · CMS fire safety

2. Sep 4, 2024 Health · 2 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 27, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     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 27, 2024 · CMS health inspection

3. May 9, 2024 Health · 11 findings
   • Not serious Scope/severity D

     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 Jun 5, 2024 · 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 Jun 5, 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 Jun 5, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0851 Administration Deficiencies

     Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

     Corrected Mar 18, 2024 · CMS health inspection

   • Not serious Scope/severity D

     K0225 Egress Deficiencies

     Have stairways and smokeproof enclosures used as exits that meet safety requirements.

     Corrected Jun 5, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0362 Smoke Deficiencies

     Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

     Corrected Jun 5, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Jun 5, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0521 Services Deficiencies

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

     Corrected Jun 5, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0912 Gas, Vacuum, and Electrical Systems Deficiencies

     Have power receptacles that are properly grounded.

     Corrected Jun 5, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Jun 5, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0927 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

     Corrected Jun 5, 2024 · CMS fire safety

4. Apr 2, 2024 Health · 2 findings
   • Not serious Scope/severity D Complaint

     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 Apr 22, 2024 · 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 Apr 22, 2024 · CMS health inspection

5. Sep 26, 2023 Health · 1 finding
   • 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 11, 2023 · CMS health inspection

6. Aug 10, 2023 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 Aug 28, 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 Aug 28, 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 Aug 28, 2023 · CMS health inspection

7. Apr 13, 2023 Health · 4 findings
   • 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 May 5, 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 May 4, 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 May 5, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0232 Egress Deficiencies

     Have corridors or aisles that are unobstructed and are at least 8 feet in width.

     Corrected May 2, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• BAUMANN, TROY — adp of the snf, NOT APPLICABLE, since 12/19/2017
• BAUMANN, TROY — corporate director, NOT APPLICABLE, since 12/19/2017
• BAUMANN, TROY — operational/managerial control, NOT APPLICABLE, since 12/19/2017
• BELONGIA, CHRISTINA — adp of the snf, NOT APPLICABLE, since 11/01/2019
• BELONGIA, CHRISTINA — operational/managerial control, NOT APPLICABLE, since 11/01/2019
• ENGEL, KAYLEE — adp of the snf, NOT APPLICABLE, since 05/31/2026
• ENGEL, KAYLEE — operational/managerial control, NOT APPLICABLE, since 05/31/2026
• GEE, DARREN — operational/managerial control, NOT APPLICABLE, since 11/30/2021
• GEE, DARREN — adp of the snf, NOT APPLICABLE, since 11/30/2021
• GREER, LAUREN — operational/managerial control, NOT APPLICABLE, since 11/29/2023
• GREER, LAUREN — adp of the snf, NOT APPLICABLE, since 11/29/2023
• HOEHN, JEFFREY — corporate director, NOT APPLICABLE, since 12/19/2017
• HOEHN, JEFFREY — adp of the snf, NOT APPLICABLE, since 12/19/2017
• HOEHN, JEFFREY — operational/managerial control, NOT APPLICABLE, since 12/19/2017
• PATZER, COLLEEN — operational/managerial control, NOT APPLICABLE, since 02/14/2023
• PATZER, COLLEEN — adp of the snf, NOT APPLICABLE, since 02/14/2023
• PURTELL, BRIAN — operational/managerial control, NOT APPLICABLE, since 06/01/2018
• PURTELL, BRIAN — adp of the snf, NOT APPLICABLE, since 06/01/2018
• WOODY, BRIAN — adp of the snf, NOT APPLICABLE, since 07/22/2024
• WOODY, BRIAN — operational/managerial control, NOT APPLICABLE, since 07/22/2024
• 101 SUNSHINE BLVD LLC — adp of the snf, NOT APPLICABLE, since 01/31/2018
• CIBC BANK USA — operational/managerial control, NOT APPLICABLE, since 12/31/2024
• CIBC BANK USA — 5% or greater security interest, NOT APPLICABLE, since 12/31/2024
• CLIFTONLARSONALLEN LLP — operational/managerial control, NOT APPLICABLE, since 05/22/2018
• CLIFTONLARSONALLEN LLP — adp of the snf, NOT APPLICABLE, since 11/03/2025
• CONTINUUM THERAPY PARTNERS LLC — operational/managerial control, NOT APPLICABLE, since 03/01/2025
• CONTINUUM THERAPY PARTNERS LLC — adp of the snf, NOT APPLICABLE, since 11/03/2025
• NICOLET NATIONAL BANK — operational/managerial control, NOT APPLICABLE, since 01/01/2018
• NICOLET NATIONAL BANK — 5% or greater security interest, NOT APPLICABLE, since 01/08/2020
• NICOLET NATIONAL BANK — 5% or greater mortgage interest, NOT APPLICABLE, since 01/08/2020
• NORTH SHORE HEALTHCARE LLC — adp of the snf, NOT APPLICABLE, since 11/03/2025
• NORTH SHORE HEALTHCARE LLC — operational/managerial control, NOT APPLICABLE, since 01/01/2018
• NSH REHAB LLC — operational/managerial control, NOT APPLICABLE, since 03/01/2025
• NSH REHAB LLC — adp of the snf, NOT APPLICABLE, since 11/03/2025
• WIPFLI LLP — adp of the snf, NOT APPLICABLE, since 11/03/2025
• WIPFLI LLP — operational/managerial control, NOT APPLICABLE, since 02/01/2025