Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Solheim Senior Community during CMS and state inspections, most recent first.
Dignity and Respect Deficiencies in Resident Care and Communication: A facility failed to maintain clean clothing, timely ADL care, and respectful communication for several residents. Residents were observed with stained or soiled clothing, one resident was addressed with terms like “Honey” and “my love” during breakfast, and another resident reported waiting for morning ADL assistance and not being told the day’s schedule. The DSD confirmed the clothing conditions, the inappropriate labels, and the delayed care were not acceptable and did not reflect resident dignity.
Failure to Maintain Fingernail Hygiene for Two Dependent Residents: Two residents who were dependent for ADLs were observed with long, untrimmed fingernails and visible debris underneath both hands. One resident had intact cognition and reported scratching himself because of dry, itchy skin, while the other resident had dementia and severe cognitive impairment. CNA and LVN staff confirmed the nails were dirty and needed cleaning, and the facility policy required assistance with grooming and personal hygiene for residents unable to perform ADLs independently.
A facility failed to ensure correct LALM settings for two residents at risk for PU. One resident with Parkinson's disease, polyneuropathy, and hip OA had a mattress set at 340 lbs. despite weighing 113 lbs., and another resident with PVD, neuropathy, dementia, and muscle weakness had a mattress set at 200 lbs. despite weighing 103 lbs. Staff stated the settings were incorrect and that the mattress could be too hard. For one resident, staff also could not find a current PO or CP for LALM use.
Cold and unappetizing meal service affected five residents during lunch. Residents reported trays arriving late or cold, hard toast, and food that was not appetizing, while tray testing found shrimp at 120-125 F and a pureed side that tasted sour or overly spiced. The RD stated shrimp should be at least 135 F, and the facility policy required meals to be palatable and served at a safe, appetizing temperature.
Improper Food Labeling and Expired Food Storage: The facility failed to label and date multiple food items in the kitchen, refrigerator, and dry storage area. A RD observed numerous frozen, refrigerated, and dry goods without open dates, prep dates, or use-by dates, and several items were found past their use-by dates. The RD stated food items must be labeled with the item name, open date, and use-by date, and the facility policy required food to be covered, labeled, dated, and discarded after expiration.
The facility failed to keep two dumpster lids closed and the dumpster area gate secured as required by policy. Surveyors observed a black and a blue dumpster with lids open, and later observed the black dumpster again with its contents exposed and the gate still not closed. The MS stated that dumpster lids were supposed to remain closed at all times to keep out flies and rodents and prevent disease transfer.
Respiratory equipment for two residents was found improperly stored and unlabeled. One resident's nasal cannula was connected to a breathing treatment machine and left hanging near the floor without a clean bag or label, while another resident's nasal cannula tubing and nebulizer mask were hanging uncovered on the wall without a clean bag or label. The IPN stated the equipment should be stored in a clean bag and labeled with the resident's name and date of first use, and the DON stated the facility did not have a policy for changing oxygen and nebulizer tubing and/or mask.
The facility failed to follow its Antibiotic Stewardship Program for two residents by not verifying the indication for ordered antibiotics and not reviewing culture and sensitivity data. One resident received IV Ertapenem for a liver abscess after transfer from the hospital, but the IPN did not review lab studies or document the antibiotic review. Another resident was ordered Fluconazole for UTI even though UTI was not an admitting diagnosis and the hospital record did not show urinalysis or urine culture and sensitivity results; the IPN had not reviewed the admission record, orders, or hospital records.
Call lights were left out of reach for three residents with significant care needs and impaired mobility/cognition. One resident’s call light was hanging behind the bed, another’s was on the floor, and a third resident’s was on the nightstand next to a nebulizer and too far to reach. Staff and the DSD confirmed the call lights should have been within reach so the residents could request assistance.
A resident with HTN, HF, and insomnia experienced disruptive noise from staff handheld radios during morning care. The resident said the radios repeatedly went off while a CNA was providing care, which upset her and made her feel she did not have the full attention of staff. An LVN and a CNA stated the radios were used daily, carried into resident rooms, and could disturb residents and interfere with care.
A resident with CHF, COPD, hypoxemia, and impaired cognition had a physician-ordered fluid restriction, but staff did not accurately monitor or document intake. Extra water was observed at the bedside, meal fluids exceeded the ordered allowance, and a CNA stated intake during meals was not recorded and that she was unaware of the fluid restriction. The RD and DON confirmed the resident’s fluid intake should have been monitored and documented per the order and facility policy.
Improper Bed Positioning During Meals: A resident with chronic respiratory failure, CHF, and dementia was observed eating in bed while the HOB was too low, including at a 60-degree angle and later below 90 degrees. The resident stated the bed was too low and asked to be sat up. Staff confirmed the HOB was not positioned high enough for eating, and an MDS nurse stated the resident should be upright at 90 degrees with the overbed table closer to the chest to reduce aspiration and choking risk.
A resident with osteomyelitis, CHF, COPD, and dementia had an inaccurate medical record when the anticoagulant monitoring order was not updated after Xarelto was discontinued and Apixaban was ordered for Afib. The MDS Nurse stated the licensed staff failed to change the bleeding-risk monitoring order to reflect the new medication, leaving the record incomplete and inaccurate under the facility’s charting policy.
A resident with severe cognitive and physical impairments, including poor sitting balance and total dependence for ADLs, was left unsupervised in a shower chair by a CNA. The resident fell, sustaining a forehead laceration and a nondisplaced C1 fracture. Staff interviews and records confirmed the resident required close supervision and that the facility lacked a reclining shower chair, which could have helped prevent the fall. Facility policy required staff to remain with residents during bathing, but this was not followed.
A resident with severe cognitive impairment and significant mobility and balance deficits did not have a comprehensive, person-centered care plan addressing these needs. Despite assessments showing poor trunk control and a high risk of falls, the care plan lacked specific interventions such as a reclining wheelchair or shower chair. This omission resulted in the resident falling in the shower room, sustaining serious injuries including a laceration, cervical fracture, and head trauma.
The facility failed to administer medications as prescribed for two residents, leading to deficiencies in pharmaceutical services. One resident was given expired diltiazem, while another missed a dose of Valproic Acid due to an empty bottle. Expired medications were also found in the storage room, posing a risk of harm if administered.
A LTC facility experienced a medication error rate of 7.1% due to two incidents. One resident was nearly given expired diltiazem ER 120 mg, and another resident did not receive their Valproic Acid 250 mg solution due to an empty bottle. Staff failed to check expiration dates and notify the pharmacy for refills, contrary to facility policy.
The facility failed to follow proper food handling practices, including labeling food items, discarding expired food, and managing damaged goods. Observations revealed unlabeled breaded fish and sausages, expired bread packs, and a dented soda can stored improperly. These deficiencies violated the facility's policy and posed a risk of foodborne illness to residents.
A long-term care facility failed to follow its infection control policy by not ensuring staff wore gowns during high-contact care activities for four residents on enhanced barrier precautions. Staff did not wear gowns during wound care and medication administration, and there was a lack of signage and PPE availability. The deficiency involved residents with conditions such as Alzheimer's, sepsis, neurocognitive disorder, and gastrostomy tubes.
A resident with severe cognitive impairment and high fall risk was left unattended during a shower, resulting in a fall and injury. The care plan lacked specific interventions for supervision and assistance during bathing, despite the resident's need for substantial assistance. Observations showed the resident walking without a walker and wearing only one non-skid sock, highlighting the inadequacy of the care plan.
A resident experienced a significant unplanned weight loss of over 5% within 30 days, which was not reported to the physician or RD as required by the facility's policy. Despite the resident's diagnoses of type 2 diabetes and severe obesity, there was no documented intervention to address the weight loss, leaving the resident at risk for further health decline.
A resident with chronic conditions requiring oxygen therapy was administered an incorrect oxygen level, set at 1 LPM instead of the prescribed 2 to 3 LPM. This was confirmed by two LVNs, who acknowledged the potential for adverse effects due to the incorrect setting, contrary to the physician's orders and facility policy.
A resident was administered quetiapine without specific target behaviors or a clear diagnosis documented, leading to inadequate monitoring of the medication's effectiveness. Facility staff acknowledged inconsistencies in the resident's diagnosis and behaviors, which were not properly documented in the medication order. This failure to adhere to the facility's policy on psychotropic medication monitoring could result in unnecessary drug use.
A facility failed to ensure proper medication labeling and storage, leading to potential harm for residents. A resident's sucralfate was mislabeled for oral administration instead of via G-tube, and expired diltiazem was found in the medication cart. Additionally, expired medications were mixed with others in the medication room, violating facility policies.
Dignity and Respect Deficiencies in Resident Care and Communication
Penalty
Summary
The facility failed to promote dignity and respect for five sampled residents by allowing dirty clothing, delayed personal care, and disrespectful forms of address. Resident 55, who had diagnoses including BPH, anxiety disorder, onychogryphosis, and a history of tobacco use, was observed sitting up in bed with dry black, ash-like fibers on his chest and brownish to blackish stains on his shirt. CNA 2 stated the resident had been chewing tobacco and had blackish particles on his chest and coffee stains on his shirt, and the DSD later stated that tobacco particles and stained clothing were not acceptable and that staff should use a clothing protector to keep residents’ clothes clean for dignity. Resident 39, who had chronic respiratory failure, CHF, and dementia and was dependent for multiple ADLs, was observed awake in bed with a brownish stain on the chest area of her shirt. The resident stated she did not know what happened or how she got the stain. The DSD confirmed the clothes were dirty and stated staff should always keep the resident’s clothes clean for dignity. Resident 27, who had chronic atrial fibrillation, CKD, and dementia, was observed during breakfast while sleeping with a tray placed in front of him. CNA 1 addressed the resident using terms such as “my love,” “Honey,” and similar labels while attempting to get him to eat, and later acknowledged she was not supposed to call the resident by those names and should address residents by name to show respect and dignity. Resident 28, admitted with generalized muscle weakness, difficulty walking, UTI, hypoosmolality, and hyponatremia, was observed lying in bed with multiple strands of white hair and dried whitish and yellowish material on her clothing at the chest and shoulder areas. The resident stated she had not gotten out of bed yet and needed help cleaning up and getting out of bed. The DSD stated morning care should have been completed by 10 AM and that the condition of the resident’s clothing was not acceptable and affected dignity. Resident 67, who had a spinal fracture, lumbar disc degeneration, generalized muscle weakness, and abnormal gait and mobility, stated she was waiting for staff to assist with brushing her teeth and did not know whether she would get a shower or just have her clothes changed. She also stated she wished staff would come in the morning to tell her the day’s schedule or when she would receive ADL assistance. The DSD stated the facility’s ADL policy was not followed and that residents should be informed of the schedule at the start of the shift so they would not be kept waiting until lunchtime.
Failure to Maintain Fingernail Hygiene for Two Dependent Residents
Penalty
Summary
The facility failed to ensure that two sampled residents who were dependent for activities of daily living received care and services to maintain good grooming and personal hygiene. Resident 55 had diagnoses including BPH, anxiety disorder, onychogryphosis, and a history of tobacco use. His MDS dated 10/23/2025 indicated intact cognitive skills for daily decision making and dependence in oral hygiene, toileting hygiene, showering/bathing, lower body dressing, footwear, bed mobility, transfers, and toileting-related care. During observation, Resident 55 was lying in bed with both hands on his abdomen, and all fingernails were long, untrimmed, and had blackish-brown debris underneath. He stated he scratched his arms, chest, and abdomen because they were dry and itchy, and that his long, sharp nails hurt him when he scratched himself. Resident 39 had diagnoses including chronic respiratory failure, congestive heart failure, and dementia. Her MDS indicated severely impaired cognitive skills for daily decision making and dependence in toileting hygiene, showering/bathing, lower body dressing, footwear, personal hygiene, bed mobility, and transfers. During observation, Resident 39 was lying in bed with both hands on her chest, and the fingernails on both hands were long, untrimmed, and had blackish-brown debris underneath. Staff interviews confirmed the condition of the resident’s nails, with CNA and LVN staff stating the nails were dirty and needed to be cleaned. Staff also stated that Resident 39 scratches her head and that dirty nails could contribute to infection if she scratched herself and developed wounds. The facility policy titled Supporting Activities of Daily Living stated that residents unable to carry out ADLs independently would receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene, including appropriate support and assistance with hygiene, bathing, dressing, grooming, and oral care. Despite this, both residents were observed with long, untrimmed fingernails and visible debris under the nails during the survey observations, and staff acknowledged the nails were dirty and in need of cleaning.
Incorrect Low Air Loss Mattress Settings for Two Residents at Risk for Pressure Ulcers
Penalty
Summary
The facility failed to implement pressure ulcer prevention treatment by not ensuring that low air loss mattresses were set at the correct settings for two residents who were identified as being at risk for pressure ulcers. Resident 24 had diagnoses including Parkinson's disease, polyneuropathy, and bilateral hip osteoarthritis, and was assessed as having a moderate risk for pressure ulcers with a Braden Scale score of 13. The physician's order directed staff to monitor the low air loss mattress every shift and adjust the setting based on the resident's weight and comfort, but during observation the mattress was found set at 340 lbs. even though the resident's recorded weight was 113 lbs. Resident 37 had diagnoses including peripheral vascular disease, peripheral neuropathy, dementia, and muscle weakness, and was assessed as at risk for pressure ulcers with a Braden Scale score of 15. The resident was observed lying in bed with the low air loss mattress set at 200 lbs. while the recorded weight was 103 lbs. Staff stated the setting was incorrect and that the mattress would be too hard at that setting. During interview, staff also stated the resident was using the mattress for skin management and had a history of redness on the buttocks. Record review and staff interviews further showed that Resident 37 did not have a current physician's order for the low air loss mattress and did not have a care plan for its use. Staff stated there should be an order and care plan to ensure proper setup, monitoring, and evaluation of the intervention. The facility's mattress manual stated the pressure level should be adjusted based on personal comfort or weight setting, and the facility's support surface guideline stated residents at risk for skin breakdown should be placed on an appropriate pressure-redistribution support surface.
Cold and Unappetizing Meal Service
Penalty
Summary
The facility failed to ensure that food was prepared and served in a palatable, attractive manner and at a safe and appetizing temperature for five sampled residents during lunch service. The deficiency was identified through observations, interviews, and record review involving Residents 2, 56, 13, 28, and 34, all of whom had intact cognitive skills for daily decision making and required varying levels of assistance with eating and personal care. The facility policy titled Resident Meal Service required residents to receive nourishing, palatable, well-balanced, attractive meals at a safe and appetizing temperature. Resident 2, who had diagnoses including hypertensive chronic kidney disease, paroxysmal atrial fibrillation, and severe protein-calorie malnutrition, stated that foods were cold and not even lukewarm, and that she had to ask a CNA to warm up coffee, soup, and food. She also stated that some foods had spice added and that she was tired of eating it, sometimes choosing not to eat because it was not a good experience. During observation, her lunch tray was delivered by a CNA and she stated the food was only warm and not as hot as expected. Resident 56, who had diagnoses including acute respiratory failure with hypoxia, pneumonia, and paroxysmal atrial fibrillation, stated that lunch was served cold at times. During lunch tray testing, a regular texture tray with grilled shrimp had a temperature of 125 F, and a pureed tray with teriyaki chicken and sweet potato was observed; the sweet potato tasted sour. The RD stated the shrimp should be at 135 F and said the pureed potato did not taste sour but tasted like more spice had been added. Resident 13, who had diagnoses including hypoosmolality, hyponatremia, and iron deficiency anemia, stated that lunch food was usually served cold and that she preferred warm food in her room. During observation, her lunch tray had not yet been delivered at 12:50 PM, and she stated staff helped other residents eat first, which caused her tray to arrive when the food was already cold. Resident 28, admitted with generalized muscle weakness, difficulty walking, UTI, hypoosmolality, and hyponatremia, stated that food arrived cold and not good, and reported being served fried potatoes and toast that were so hard she could not eat them. She also stated she filled out the menu for foods she wanted but did not receive the foods she chose. Resident 34, who had diagnoses including hypertensive chronic kidney disease, unspecified protein-calorie malnutrition, vitamin D deficiency, and prediabetes, stated she wanted her meal tray on time and the food warm, but that trays arrived past 12:30 PM and were already cold. During lunch tray testing, fried breaded shrimp measured 120 F, and the RD and Director of Dining Services stated the ideal temperature should be 135 F or more and that the shrimp was cold.
Improper Food Labeling and Expired Food Storage
Penalty
Summary
The facility failed to follow proper food storage and handling practices in accordance with its policy and procedure by not ensuring that food items were labeled and discarded after their use-by date. During a concurrent observation and interview in the kitchen with the Registered Dietitian, multiple frozen items were found without labels showing an open date or use-by date, including mini empanadas, ravioli, Asian noodle, and chocolate chip cookies. Other frozen items were found with use-by dates that had already passed, including tuna and frozen banana. Additional observations in the refrigerator and dry storage area showed numerous unlabeled or improperly labeled items, including chopped honeydew, cantaloupe, carrot, tomato, salad dressing, cheese, hamburgers patties, chicken breast, bacon, thawing minced meat, turkey sandwich, cut apples soaked in water, rice crispy, chocolate fudge icing, mini mush marrow, Cajun seasoning, old bay seasoning, low-fat cultured buttermilk, light amber honey, and mayonnaise. Several items were also observed with use-by dates that had passed, including pumpkin sauce, marinara sauce, cranberry sauce, turkey slice, chicken noodle soup, and parmesan cheese. The Registered Dietitian stated that food items should be labeled with an open date and use-by date once opened, should include the specific name and preparation date, and must be discarded after the use-by date. The facility policy titled Food and Supply Storage also required food to be covered, labeled, dated, and discarded past the use-by or expiration date.
Dumpster Lids Left Open and Gate Unsecured
Penalty
Summary
The facility failed to ensure that two of two garbage containers in the alley dumpster area remained closed as required by its policy and procedure titled, Garbage Disposal & Waste Management. During an observation on 12/16/2025 at 1:53 PM, two dumpsters, one black and one blue, were seen with lids left open, and the black dumpster area gate was not closed. During a later observation on 12/18/2025 at 8:24 AM, the black dumpster was again observed with its lids open and the contents exposed, and the dumpster area gate was still not closed. During interview on 12/18/2025 at 8:52 AM, the Maintenance Supervisor stated that per facility policy, all dumpster lids were supposed to be kept closed at all times and kept clean to keep out flies and rodents and to prevent transfer of disease. The facility policy dated 11/1/2019 stated that dumpsters and compactors shall remain closed when not in use.
Respiratory Equipment Not Properly Stored or Labeled
Penalty
Summary
Standard infection prevention and control practices were not followed for two residents receiving respiratory equipment. Resident 56 was admitted and readmitted with diagnoses including acute respiratory failure with hypoxia, pneumonia, and paroxysmal atrial fibrillation. The quarterly MDS indicated intact cognitive skills for daily decision making, but the resident required varying levels of assistance with personal care and was dependent for several activities including toileting hygiene, bathing, dressing, and transfers. A physician order dated 5/23/2025 included ipratropium-albuterol solution every six hours as needed for acute respiratory failure with hypoxia. During observation on 12/15/2025, Resident 56's nasal cannula was found connected to the breathing treatment machine and hanging between the nightstand and curtain close to the floor. The cannula was not stored in a clean bag and was not labeled with the resident's name or date of first use. During interview, the LVN stated the breathing treatment and nasal cannula were supposed to be inside a clean bag when not in use and labeled with the resident's name and date it was opened or first used. The IPN stated the nasal cannula should be labeled so staff would know when it was opened and when to discard or change it, and stated that leaving it exposed or not keeping it in a clean bag could put the resident at risk for infection. Resident 5 was admitted and readmitted with diagnoses including respiratory failure with hypoxia and systolic congestive heart failure. The MDS indicated intact cognitive skills for daily decision making and varying levels of assistance with eating, hygiene, bathing, dressing, and toileting. The order summary included oxygen administration as needed by nasal cannula and daily oxygen tubing and humidifier changes. During observation on 12/15/2025, the resident's nasal cannula tubing and nebulizer mask were hanging on the wall without labels showing the resident's name or date of first use, and they were not stored in a clean bag. The IPN stated the equipment should not be left uncovered and should be labeled with the resident's name and date opened, and the DON stated the facility did not have a policy for changing oxygen and nebulizer tubing and/or mask.
Failure to Review Antibiotic Indications and Culture Results
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program for two residents by not verifying the indication for antibiotic use and not reviewing supporting laboratory testing such as culture and sensitivity results. The facility's policy stated that antibiotics should be prescribed and administered under the guidance of the Antibiotic Stewardship Program and that appropriate indications include clinical criteria for active infection or suspected sepsis and pathogen susceptibility based on culture and sensitivity. Resident 26 was admitted with diagnoses including liver abscess, severe sepsis, and bacteremia. The resident's MDS indicated intact cognitive skills and that the resident was receiving antibiotics through a PICC line. The order summary showed Ertapenem Sodium 1 gram IV daily for liver abscess for four weeks. During interview, the IPN stated the medication had been continued from the acute hospital, but she was not familiar with what to check under the antibiotic stewardship program and did not review the resident's laboratory studies, including culture and sensitivity, or other studies related to the indication for the antibiotic. The IPN stated this review should have been completed and documented when the resident was admitted. Resident 68 was admitted with an unstageable sacral pressure ulcer. The MDS indicated moderately impaired cognitive skills and dependence or substantial assistance with several activities of daily living. The order summary showed Fluconazole 200 mg by mouth daily for UTI for 10 days, but the admission record did not include a diagnosis of UTI and the hospital records did not include urinalysis or urine culture and sensitivity results. The IPN stated she had not reviewed the admission record, order summary, or hospital records since admission, confirmed that UTI was not among the admitting diagnoses, and acknowledged that no urine culture and sensitivity test was done for the Fluconazole order.
Call Lights Left Out of Reach for Three Residents
Penalty
Summary
The facility failed to ensure that resident call lights were within reach for three sampled residents. The report states that Resident 55, Resident 36, and Resident 33 each had call lights placed out of reach during observations, despite facility policy requiring the nurse call system to be plugged in and within the resident’s reach at all times. The deficiency was identified through observation, interview, and record review. Resident 55 was admitted and re-admitted to the facility with diagnoses including BPH, anxiety disorder, and muscle wasting/atrophy. The MDS dated 10/23/2025 indicated intact cognitive skills for daily decision making and dependence in multiple ADLs, including toileting hygiene, bathing, dressing, transfers, and mobility. The care plan for high fall risk directed staff to ensure the call light was within reach and to encourage use for assistance as needed. During observation, Resident 55 was sitting in bed sleeping, and the call light was hanging at the back of the bed frame and not within reach. The DSD later moved the call light into the resident’s hands and stated that if it was hanging behind the bed or on the floor, the resident would not be able to use it to call for help. Resident 36 was admitted and re-admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, heart failure, and history of falling. The MDS dated 10/22025 indicated severely impaired cognitive skills for daily decision making and dependence in oral hygiene, toileting hygiene, bathing, dressing, transfers, and mobility. During observation, Resident 36 was sleeping, then woke up and asked for the call light, which was found on the floor. CNA 6 placed it within reach and stated that residents need their call lights within reach so they can press them to call for help. Resident 33 was admitted and re-admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, COPD, and hypoxemia. The MDS indicated moderately impaired cognitive skills and dependence in toileting hygiene, bathing, dressing, and footwear, with supervision or touching assistance needed for eating and oral hygiene. During observation, Resident 33’s call light was on the nightstand next to a nebulizer and not within reach; the resident stated it was too far to reach. CNA 4 then placed the call light in the resident’s hands, and the DSD stated it should not have been left on the nightstand and should be within reach so the resident could request assistance in a timely manner.
Disruptive Staff Radio Noise During Resident Care
Penalty
Summary
The facility failed to maintain a comfortable sound level for one of twenty sampled residents, Resident 31, during care and daily activities. Resident 31 was admitted on 1/13/2021 and readmitted on 7/11/2023 with diagnoses including hypertension, heart failure, and insomnia. The resident's MDS dated 10/29/2025 indicated adequate hearing, intact cognitive skills for daily decision making, and varying levels of assistance with activities of daily living, including set up or clean up assistance for eating, oral hygiene, and personal hygiene; partial/moderate assistance for upper body dressing; and dependence for toileting hygiene, bathing, lower body dressing, footwear, and several transfers. During an observation and interview on 12/16/2025, Resident 31 was awake in bed and stated that handheld radios carried by staff disturbed her. She reported that the CNA assigned to her had a radio that repeatedly went off during morning care to request the CNA to pick up a tray from another room, and she felt upset and did not have the full time and attention of staff. In interviews on 12/18/2025, an LVN stated the radios were used every day, staff carried them all the time including inside residents' rooms, and residents had complained or asked what the noise was when the radios went off. The LVN and a CNA stated the radio noise could be disruptive to residents' everyday lives and could disturb residents during care. The Administrator reviewed the facility's Accommodation of Needs policy, which stated staff should conduct rounds and visual inspections to see whether the environment accommodates residents' needs and preferences, including maintaining a comfortable sound level.
Failure to Monitor Fluid Restriction Intake
Penalty
Summary
The facility failed to accurately monitor the fluid intake for one resident who had a physician’s order for a 1600 ml fluid restriction per 24 hours. The resident’s diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, COPD, hypoxemia, and chronic diastolic congestive heart failure. The MDS dated 9/24/2025 indicated the resident had moderately impaired cognitive skills for daily decision making and was dependent for toileting hygiene, showering/bathing, lower body dressing, and putting on/taking off footwear, with supervision or touching assistance needed for eating and oral hygiene. The physician’s order dated 8/21/2025 specified 720 ml for meals and 880 ml for nursing, divided across the three shifts. During an observation on 12/16/2025, three cups of water, each containing 8 fluid ounces, were seen on the resident’s bedside table. An LVN stated the resident was on fluid restriction and should not have had three 8-ounce cups of water at bedside, and that staff should have removed the extra water. During a later observation, the resident was seen eating breakfast and drinking coffee and orange juice; the breakfast ticket listed 6 oz coffee, 2 oz coffee creamer, 4 oz orange juice, 6 oz strawberry yogurt, and 6 oz cream of wheat. The resident stated she did not know she was on fluid monitoring. During lunch observation, the resident had an 8 oz cup of juice and a 12 oz cup of water in front of her. A CNA stated the resident did not have a meal ticket indicating fluid restrictions and confirmed that fluid intake during meals was not recorded. The CNA stated she did not know the resident had an order for fluid restriction and fluid intake monitoring. The RD confirmed the resident was on fluid restriction and stated the breakfast fluid amount was over the ordered 240 ml limit, and that fluid intake was supposed to be monitored for all meals including lunch and dinner. The DON stated CNAs should have removed extra water from the bedside and that the RD needed to monitor oral fluid intake during meals to ensure compliance with the physician’s order. The facility policy stated fluid restrictions are to be monitored by nursing staff, with all oral and enteral fluid intake tracked and documented every shift, and meal trays reflecting fluid restrictions.
Improper Bed Positioning During Meals
Penalty
Summary
The facility failed to provide interventions to prevent accidents for one sampled resident by not ensuring the head of the bed was upright or elevated to a 90-degree angle during mealtimes. Resident 39 was admitted and re-admitted to the facility with diagnoses including chronic respiratory failure, congestive heart failure, and dementia. The resident’s MDS dated 10/20/2025 indicated moderately impaired cognitive skills for daily decision making, dependence for multiple ADLs, and need for setup or clean-up assistance when eating. The care plan for ADL self-care performance deficit related to acute respiratory failure included an intervention for the resident to receive set up/supervision by one staff member to eat. During an observation on 12/16/2025, Resident 39 was awake and lying in bed while trying to eat, and stated the head of the bed was too low and asked to be sat up. The head of the bed was observed at a 60-degree angle, and then observed again below a 90-degree angle when a CNA entered the room and stated it was too low and should be placed at 90 degrees. An LVN later stated the head of the bed was too low for the resident to eat and should be upright to 90 degrees when eating or drinking water because residents are at risk for aspiration and aspiration pneumonia. An MDS nurse stated the resident should be positioned correctly, sitting up with the head of the bed elevated to 90 degrees and the overbed table closer to the chest to prevent aspiration and choking. The facility policy for preparing a resident for a meal stated residents served in bed should be properly positioned in a nearly upright sitting position to lessen the possibility of choking.
Inaccurate anticoagulant monitoring order in resident record
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one resident. Resident 30 was admitted and re-admitted to the facility with diagnoses including osteomyelitis of the right ankle/foot, CHF, COPD, and dementia. The resident’s MDS dated 11/17/2025 indicated severely impaired cognitive skills for daily decision making and dependence in multiple areas of care, including eating, oral hygiene, toileting hygiene, bathing, dressing, footwear, personal hygiene, and transfers. A review of the physician’s orders showed the resident was started on Xarelto 15 mg daily on 1/21/2025 for CVA prophylaxis and later discontinued on 7/22/2025, when Apixaban 2.5 mg twice daily was ordered for Afib. During interview and record review, the MDS Nurse stated the licensed staff did not change the risk for bleeding monitoring order from Xarelto to Apixaban. The facility’s Charting and Documentation policy stated documentation must be objective, complete, and accurate, and the MDS Nurse stated the monitoring order was inaccurate because it still reflected the wrong anticoagulant medication name.
Resident Left Unattended in Shower Chair Resulting in Fall and Injury
Penalty
Summary
A deficiency occurred when a resident, who was assessed as dependent for all activities of daily living (ADLs) and had poor sitting balance, was left unattended in a shower chair by a certified nurse assistant (CNA). The resident's care plan and mobility assessment documented significant cognitive and physical impairments, including severe cognitive deficits, poor trunk control, and inability to maintain sitting or standing balance. Despite these documented needs, the CNA turned her back on the resident while the resident was in the shower chair, leaving the resident unsupervised. As a result of being left unattended, the resident fell from the shower chair in the shower room, sustaining a laceration to the forehead and an acute nondisplaced fracture of the first cervical vertebra (C1). The resident was transported to a general acute care hospital, where additional injuries, including a forehead hematoma and blunt head trauma, were diagnosed. Interviews with facility staff confirmed that the resident required total assistance during showers and that the facility's shower chair could not be reclined, which may have contributed to the resident's inability to maintain balance. Further review of facility policies indicated that staff were required to stay with residents throughout bathing and never leave them unattended in the tub or shower. Staff interviews and documentation confirmed that the resident was not using a reclining wheelchair or shower chair prior to the incident, despite recommendations that such equipment could have helped prevent falls for residents with poor balance and trunk control. The failure to provide adequate supervision and appropriate equipment directly led to the resident's fall and subsequent injuries.
Failure to Develop and Implement Comprehensive Care Plan for Resident with Poor Mobility and Balance
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes to address a resident's poor mobility and balance, as required by facility policy. The resident, who had diagnoses including Alzheimer's disease, cerebral infarction, and dementia, was assessed as having severe cognitive impairment and was dependent on staff for all activities of daily living, including transfers and personal hygiene. Despite documented poor trunk control, poor sitting and standing balance, and a tendency to lean forward or to the sides, the care plan only indicated general assistance with activities of daily living and did not specifically address the resident's mobility and balance deficits. Multiple assessments, including the Minimum Data Set and a mobility assessment, identified the resident as having poor ability to sit up unassisted and maintain balance, requiring total assistance while seated in a wheelchair or shower chair. Interviews with the Director of Rehabilitation and the MDS nurse confirmed that the resident's poor trunk control and tendency to lean forward or to the sides increased the risk of falls, and that interventions such as a reclining wheelchair or shower chair could have provided additional safety. However, these specific interventions were not included in the resident's care plan, and the facility did not have a reclining shower chair available for use. As a result of these omissions, the resident sustained a fall in the shower room while sitting in a shower chair, resulting in a laceration to the forehead, a nondisplaced fracture of the first cervical vertebra, a forehead hematoma, and blunt head trauma. The incident led to the resident being sent to an acute care hospital for further evaluation and treatment. Facility leadership confirmed that a care plan addressing the resident's poor mobility and balance was not developed prior to the fall, despite assessments indicating the need for such interventions.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents, leading to deficiencies in medication administration. For Resident 16, the facility did not administer diltiazem, a medication for high blood pressure and angina, as ordered by the physician. During a medication observation, it was found that the diltiazem bottle was expired, yet it was still prepared for administration. The Licensed Vocational Nurse (LVN) acknowledged the oversight and admitted that expired medications should not be in the medication cart, as they could lead to ineffective treatment or harm to the resident. Additionally, the facility was found to have expired medications in the medication storage room, including two bottles of buspirone and three bottles of blood sugar check machine control solution. These expired items were mixed with other medications, posing a risk of administration to residents. An LVN confirmed the presence of expired medications and emphasized that they should not be mixed with other medications, even if unopened, as this could cause harm if administered. For Resident 53, the facility failed to administer Valproic Acid as prescribed due to an empty medication bottle. The LVN discovered the empty bottle during a medication review and found no replacement in the medication room. The LVN stated that the doctor and pharmacy should have been notified immediately to prevent a missed dose. The facility's policy indicated that medications should be administered according to prescriber's orders and that expired medications should not be given to residents.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 7.1% error rate during a medication pass observation. This was due to two medication errors out of twenty-eight opportunities. The first error involved Resident 16, who was administered an expired medication, diltiazem ER 120 mg, which was intended for hypertension and paroxysmal atrial fibrillation. The LVN responsible for administering the medication did not check the expiration date, which was past due, and acknowledged that administering expired medication could lead to the resident not receiving the correct dose or desired effect. The second error involved Resident 53, who was dependent on staff for daily activities and had multiple diagnoses, including dysphagia and paranoid schizophrenia. During the medication pass, it was discovered that the bottle of Valproic Acid 250 mg solution was empty, and no replacement was available in the medication room. The LVN did not notify the doctor or pharmacy immediately, which resulted in the resident not receiving their medication on time. The facility's policy requires that medications be checked for expiration and availability, and that the pharmacy and doctor be notified when a medication is running low or empty. Interviews with staff, including the MDS Nurse, confirmed that expired medications should not be present in the medication cart and that immediate action should be taken to refill medications to prevent harm to residents. The facility's policies on medication administration and ordering emphasize the importance of maintaining an adequate supply of medications and ensuring that expired medications are not administered.
Improper Food Handling Practices in Facility Kitchen
Penalty
Summary
The facility failed to adhere to proper food handling practices as outlined in its policy and procedure, leading to several deficiencies. During observations, it was noted that food items in the kitchen were not labeled with preparation or expiration dates. Specifically, a tray of breaded fish and an open box of sausages lacked labels indicating when they were prepared or opened. Additionally, a bread rack contained approximately 35 packs of bread that were past their expiration date, and a bag of walnuts and almonds were not labeled with an open date. These lapses in labeling and discarding expired food items could potentially expose residents to pathogens and increase the risk of foodborne illnesses. Further observations revealed that the facility did not properly manage damaged food items. A dented soda can was found stored among other beverages instead of being placed in a designated area for damaged goods. Additionally, five overripe bananas were observed in the refrigerator, which were deemed unfit for consumption. These practices were in direct violation of the facility's policy, which mandates that all food items be stored to prevent contamination, expired food be discarded, and damaged items be segregated for return. The failure to follow these procedures placed residents at risk of consuming unsafe food.
Infection Control Deficiency in LTC Facility
Penalty
Summary
The facility failed to adhere to its infection control policy by not ensuring that staff wore gowns while providing care to residents on enhanced barrier precautions (EBP). This deficiency was observed in four residents who required high-contact care activities. For Resident 19, who had Alzheimer's disease and was dependent on staff for daily activities, staff did not wear gowns during wound care treatment. The treatment nurse and certified nurse assistant involved admitted to not wearing gowns and acknowledged the absence of EBP signage and documentation in the resident's care plan. Similarly, Resident 60, who had sepsis, a Foley catheter, and a sacral pressure ulcer, did not receive care with the required infection control measures. During wound care treatment, staff failed to wear gowns, and there was no signage or PPE cart outside the resident's room to alert staff and visitors. The infection preventionist nurse confirmed the need for PPE during such high-contact activities, but the staff involved were unaware of the requirement. Resident 9, with neurocognitive disorder and diabetes, also did not receive proper infection control measures during wound care. Staff did not wear gowns, and their clothing came into contact with the resident's bed and arms. The facility's policies indicated the necessity of PPE during high-contact activities, but staff failed to follow these guidelines. Additionally, Resident 53, who had a gastrostomy tube, was not provided care with the appropriate PPE, as the licensed vocational nurse did not wear a gown during medication administration, despite the resident's physical contact with the nurse.
Failure to Implement Comprehensive Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered care plan for a resident who experienced an actual fall on 6/13/2024. The resident, who has severe cognitive impairment, reduced mobility, and is at high risk for falls, was left unattended during a shower by facility staff. This occurred when a Certified Nurse Assistant (CNA) turned away to dispose of soiled clothes, resulting in the resident attempting to self-transfer to his walker, losing balance, and falling. The fall resulted in a laceration on the resident's left hand and redness on the left hip. The care plan initiated on 6/13/2024 did not include specific interventions to supervise and provide assistance to the resident during bathing, despite the resident's high fall risk and need for substantial assistance. The resident's Minimum Data Set (MDS) indicated a requirement for maximal assistance with showering and substantial assistance for walking. However, the care plan failed to address these needs adequately, lacking instructions for supervision during transfers and walking, as well as assistance during bathing. Observations on 10/8/2024 revealed the resident getting up from bed and walking to the restroom without using a walker, wearing only one non-skid sock. Interviews with facility staff confirmed the resident's high fall risk and the need for supervision and assistance, which were not reflected in the care plan. The facility's policies and procedures require care plans to be modified and reviewed when there is a significant change in the resident's condition, but this was not done effectively for the resident in question.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to address a significant unplanned weight loss of over 5% within 30 days for a resident, identified as Resident 62. The resident, who was admitted with diagnoses including type 2 diabetes and severe obesity, experienced a weight loss from 180 pounds to 170 pounds over the course of a month. This weight loss was identified as significant by the Licensed Vocational Nurse (LVN 1) and the Minimum Data Set Nurse (MDSN), who noted that the weight loss should have been reported to the resident's physician or a Registered Dietitian (RD) for intervention. However, there was no documented evidence that such notifications were made, and the resident's weight loss was not addressed according to the facility's policy. The facility's policy required that any weight change of 5% or more be confirmed and that the multidisciplinary team should intervene for undesirable weight loss. Despite this, the resident's significant weight loss was not communicated to the necessary medical professionals, and no interventions were documented. The Registered Dietitian confirmed that there was no record of addressing the weight loss, and the last note from the RD was made prior to the weight loss. The facility's failure to notify the physician or RD and to implement necessary interventions left the resident at risk for further health decline.
Failure to Administer Correct Oxygen Level
Penalty
Summary
The facility failed to administer the correct oxygen level to a resident, identified as Resident 16, in accordance with the physician's order. The resident was admitted with diagnoses including chronic congestive heart failure, type 2 diabetes, and sleep apnea, and required oxygen therapy. The physician's orders specified that oxygen should be administered at 2 to 3 liters per minute (LPM) every shift. However, during an observation, it was noted that the oxygen was set at 1 LPM, which was below the prescribed level. Licensed Vocational Nurse 1 confirmed that the oxygen setting was incorrect and acknowledged that the resident was supposed to receive 2 LPM. This discrepancy was further corroborated by Licensed Vocational Nurse 2, who reiterated the physician's orders and the potential for the resident to experience shortness of breath and decreased oxygenation if the oxygen level was not set correctly. The facility's policy on oxygen administration also indicated that the flow should be set at 2 to 3 LPM, highlighting a failure to adhere to both the physician's orders and the facility's own procedures.
Failure to Document Specific Target Behaviors for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from the unnecessary use of psychotropic drugs, specifically quetiapine, as per the facility's policy and procedure. The resident, who was diagnosed with schizophrenia, major depressive disorder, and anxiety disorder, was administered quetiapine without a specific target behavior or indication for its use being documented. The resident's care plan and physician's orders did not clearly specify the behaviors for which the medication was prescribed, leading to a lack of proper monitoring and evaluation of the medication's effectiveness. Interviews with facility staff, including a Licensed Vocational Nurse, MDS Nurse, Social Service Designee, and Assistant Director of Nursing, revealed inconsistencies and a lack of clarity regarding the resident's diagnosis and the specific behaviors that warranted the use of quetiapine. The staff acknowledged that the resident exhibited behaviors such as screaming, hallucinations, and verbal aggression, but these were not documented as specific target behaviors in the medication order. The staff also confirmed that the resident's face sheet did not list schizoaffective disorder, which was the stated reason for the quetiapine prescription. The facility's policy on monitoring psychotropic medications requires thorough documentation and evaluation of the medication's effectiveness and potential adverse effects. However, the lack of specific target behaviors in the resident's medication order and the absence of a documented diagnosis of schizoaffective disorder indicate a failure to adhere to these guidelines. This deficiency in documentation and monitoring could potentially lead to the resident receiving medication without a clear therapeutic goal or understanding of its necessity.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that medications were labeled and stored correctly, leading to potential harm for residents. In the case of Resident 53, the medication bottle for sucralfate was incorrectly labeled with instructions to take the medication by mouth, while the physician's orders and the Medication Administration Record (MAR) indicated it should be administered via a gastrostomy tube (G-tube). This discrepancy was observed during a medication administration by an LVN, who followed the MAR instructions but did not verify the label on the medication bottle. The LVN acknowledged the error and stated that the pharmacy provided the incorrect label, which should have been clarified with the doctor or pharmacy before administration. Resident 16 was at risk due to the presence of expired diltiazem medication in the facility's medication cart. During a medication observation, an LVN prepared to administer the expired medication, which had an expiration date that had already passed. The LVN admitted that the medication carts are usually checked every morning, but she failed to verify the expiration date of the medication before preparing it for administration. The presence of expired medication in the cart could lead to the resident not receiving the correct dosage or desired effect of the medication. Additionally, during an inspection of the facility's medication room, multiple expired medications were found mixed with other medications. This included unopened bottles of Buspirone and a control solution for blood sugar testing, both of which were past their expiration dates. An LVN confirmed the presence of these expired medications and acknowledged that they should not be mixed with other medications, as administering expired medications could cause harm to residents. The facility's policy and procedure guidelines clearly state that no expired medication should be administered and that medication labels should be checked against the MAR before administration.
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 6,719 citations issued within 25 miles in the last 12 months — including the 34 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 Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ararat Convalescent Hospital | 0.1 mi | ★★★★★ | 16 | 0 |
| College Vista Post-acute | 0.6 mi | ★★★★★ | 0 | 0 |
| Glendale Adventist Medical Center Dp/snf | 1 mi | ★★★★★ | 16 | 0 |
| Ararat Post Acute | 1.1 mi | ★★★★★ | 20 | 0 |
| Glendale Post Acute Center | 1.4 mi | ★★★★★ | 24 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Solheim Senior Community.
100% money-back within 48 hours.
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.