Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Solomon Valley Manor during CMS and state inspections, most recent first.
The facility failed to provide adequate supervision and implement necessary interventions to prevent falls for two residents, resulting in major injuries. Despite having severe cognitive impairments and being at high risk for falls, the facility did not conduct thorough investigations or update care plans with effective interventions, leading to repeated falls and injuries.
A resident experienced a significant unintended weight loss of 9.74% over three months due to the facility's failure to implement the Registered Dietician's recommended nutritional interventions. Despite the resident's severe cognitive impairment and need for assistance with eating, the facility did not provide the suggested supplements. Staff interviews revealed communication lapses and procedural oversights, contributing to the deficiency.
The facility failed to ensure the medical director attended QAPI meetings quarterly from May to September 2024, as required. This absence was confirmed by administrative staff and no policy was provided, placing residents at risk for decreased quality of care.
A resident with multiple medical conditions was hospitalized twice, but the facility failed to provide the required bed hold policy notice to the resident or their representative. This oversight was confirmed by staff, who acknowledged that the notice was not given at the time of discharge, contrary to the facility's policy.
Two residents with severe cognitive impairment experienced multiple falls due to the facility's failure to update their care plans with new interventions. Despite a history of falls and significant injuries, the facility did not conduct thorough investigations or implement effective preventive measures, leaving the residents at risk for further injuries.
A resident with severe cognitive impairment and a recent hip fracture developed pressure ulcers due to the facility's failure to implement and update necessary interventions. Despite having a care plan and physician orders for pressure ulcer prevention, the facility did not consistently follow these measures, leading to the worsening of the resident's condition.
A facility failed to ensure the Consultant Pharmacist identified and reported the absence of a stop date for a resident's PRN Ativan, as required by CMS. The resident, with anxiety disorder, vascular dementia, and recurrent major depressive disorder, was at risk due to the continued use of psychotropic medication beyond 14 days. Despite the physician's orders being marked as indefinite, the CP did not request a stop date during medication reviews, and the physician did not respond to the CP's request for a risk versus benefit statement.
The facility failed to obtain stop dates for PRN Ativan for two residents, leading to unnecessary psychotropic medication use. One resident had anxiety, dementia, and depression, with non-pharmacological interventions in place, but the Ativan order was indefinite. Another resident with heart failure and impaired cognition also had an indefinite Ativan order. Observations showed behavioral issues and mobility assistance needs. The facility's policy required a 14-day limit or documented rationale for extension, which was not followed.
The facility failed to maintain sanitary food preparation practices when two residents requested a lettuce salad. Dietary staff handled the lettuce with contaminated gloves after touching a trash can lid and intended to serve it to residents. The facility's policy requires changing gloves and washing hands after contamination, which was not followed, placing residents at risk for foodborne illness.
Failure to Prevent Falls and Implement Interventions
Penalty
Summary
The facility failed to provide adequate supervision and implement necessary interventions to prevent falls for two residents, resulting in major injuries. Resident 23, who had severe cognitive impairment and multiple health issues, experienced several falls, including one that resulted in a hip fracture. Despite having a history of falls and being at high risk, the facility did not conduct thorough investigations to identify causative factors or update the care plan with effective interventions to prevent further incidents. The lack of investigation and intervention left Resident 23 vulnerable to repeated falls and injuries. Similarly, Resident 24, who also had severe cognitive impairment and a history of falls, was not adequately supervised or provided with effective interventions to prevent falls. The resident had multiple falls, some resulting in injuries, and the facility failed to conduct proper investigations or update the care plan with necessary interventions. Despite being at high risk for falls and requiring assistance with transfers, the facility did not ensure that Resident 24 was adequately monitored or assisted, leading to repeated falls. The facility's policy required that all falls, whether witnessed or unwitnessed, be investigated and interventions put in place to prevent recurrence. However, the facility did not adhere to this policy, as evidenced by the lack of investigations and interventions following the falls of Residents 23 and 24. This failure to follow policy and implement necessary measures placed both residents at risk for ongoing falls and injuries.
Failure to Implement Nutritional Interventions for Resident
Penalty
Summary
The facility failed to recognize and act upon a significant weight loss in Resident 23, who experienced a 9.74% unintended weight loss over three months. Despite the Registered Dietician's (RD) recommendations to prevent further weight loss, the facility did not implement the suggested nutritional interventions. Resident 23, who had severe cognitive impairment and required assistance with eating, was not provided with the recommended nutritional supplements, which included an eight-ounce house supplement or shake in the afternoon, and later, additional supplements and vitamins for healing and weight maintenance. Resident 23's medical history included severe dementia, hypertension, anxiety, depression, insomnia, and other conditions. The resident was dependent on staff for various activities of daily living and had a pressure ulcer requiring care. The RD had noted the resident's weight loss and recommended specific dietary interventions to address the issue, but these were not implemented by the facility. The resident's weight continued to decline, and the clinical record lacked evidence of the facility's action on the RD's recommendations. Interviews with facility staff revealed a lack of communication and follow-through on the RD's recommendations. The dietary manager was supposed to report the RD's recommendations to the nursing department for physician orders, but this did not occur. Staff changes and scheduling issues were cited as reasons for the oversight. The facility's policy required monitoring of residents' weights and notification of the physician for significant weight changes, but this protocol was not followed for Resident 23.
Medical Director's Absence from QAPI Meetings
Penalty
Summary
The facility, with a census of 29 residents and a sample of 12 residents, was found to lack evidence of the required committee members' attendance at the Quality Assurance Performance Improvement (QAPI) meetings. Specifically, the medical director did not attend the QAPI meetings quarterly, as required, during the period from May through September 2024. This was confirmed by Administrative Staff A, who verified that the medical director did not attend a QAPI meeting in the third quarter of 2024. The facility also failed to provide a policy regarding this requirement. This deficiency placed the residents at risk for decreased quality of care.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a resident, identified as R28, with a bed hold policy as required during instances of hospitalization. R28's electronic medical record indicated multiple diagnoses, including anemia, major depressive disorder, heart failure, and diabetes mellitus. The resident was discharged from the facility with a return anticipated on multiple occasions, as documented in the Minimum Data Set (MDS). On two separate occasions, R28 was sent to the hospital for medical evaluation and treatment, once for elevated blood pressure and weakness, and another time for intravenous antibiotic treatment for an infection. However, the clinical record lacked evidence that the resident or their representative received a copy of the bed hold notice during these hospitalizations. Upon review, the facility was unable to provide documentation that a bed hold notice was given to R28 or their representative. Administrative Staff A confirmed that residents are typically given a transfer bed hold policy upon admission, with the original kept in the chart. However, it was verified that R28 or their representative did not receive this notice at the time of discharge. The facility's Bed Hold Policy, dated 04/10/24, mandates providing written information to residents or their representatives regarding the duration of the bed hold policy when transferring to a hospital or during therapeutic leave. The failure to provide this notice placed R28 at risk of being unable to return to the facility in the same room or bed.
Failure to Update Care Plans for Fall Prevention
Penalty
Summary
The facility failed to adequately review and revise the care plans for two residents, leading to deficiencies in preventing falls and pressure ulcers. Resident 23, who had a history of falls and severe cognitive impairment, experienced multiple falls resulting in significant injuries, including fractures. Despite these incidents, the facility did not update the care plan with new interventions to prevent further falls. The care plan lacked specific strategies to address the resident's confusion, incontinence, and balance difficulties, which were contributing factors to the falls. Additionally, the facility did not conduct thorough investigations to identify the root causes of the falls, further hindering the implementation of effective preventive measures. Resident 24, who also had severe cognitive impairment and a history of falls, was admitted with a fracture and continued to experience falls during self-transfers. The care plan for this resident was not updated with new interventions after each fall, and the facility failed to complete fall investigations to determine the causes and implement appropriate preventive strategies. The resident's care plan included repeated interventions, such as ensuring the use of gripper socks and monitoring with a video camera, but these measures were insufficient to prevent further falls. The lack of timely updates and investigations left the resident at risk for additional injuries. The facility's Plan of Care policy mandates that care plans be developed and maintained for each resident, with reviews conducted as necessary and at least quarterly. However, the facility did not adhere to this policy, as evidenced by the lack of updated interventions and investigations for both residents. The failure to communicate and implement resident-centered interventions placed both residents at risk for further injuries due to unaddressed care needs.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate interventions to prevent a facility-acquired pressure ulcer on a resident's heel following a significant change in mobility. The resident, identified as R23, had a history of severe cognitive impairment, dementia, and other medical conditions, including a recent hip fracture. Upon returning from the hospital, R23 developed a Stage 1 pressure ulcer on the outer left ankle and a Stage 2 pressure ulcer on the left heel. Despite having a care plan that included the use of foam boots and a pressure-reducing mattress, the facility did not consistently implement these interventions. Observations and records indicated that the facility did not update R23's care plan with necessary interventions to address the pressure ulcers. The resident's care plan initially documented no skin issues upon admission and identified a mild risk for pressure ulcers. However, as the resident's condition changed, the facility failed to adjust the care plan accordingly. The resident's physician had ordered specific treatments, including cleansing the open area, applying collagen, and floating the heels with pillows, but these interventions were not consistently followed. Interviews with staff revealed inconsistencies in the implementation of pressure ulcer prevention measures. For instance, the resident was observed sitting in a wheelchair without a pillow behind the legs, contrary to the physician's orders. Additionally, the administrative nurse confirmed that the care plan had not been updated with the necessary interventions. The facility's policy on pressure ulcer prevention emphasized the need for individualized care plans and regular assessments, but these were not adequately executed, leading to the deficiency.
Consultant Pharmacist Fails to Ensure Stop Date for PRN Ativan
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported the absence of a stop date for the PRN Ativan prescribed to Resident 14, as required by the Center for Medicare and Medicaid Services (CMS). Resident 14, who had diagnoses of anxiety disorder, vascular dementia, and recurrent major depressive disorder, was at risk for complications due to the continued use of psychotropic medication beyond 14 days. The resident's care plan included non-pharmacological interventions for anxiety, but also allowed for the administration of PRN Ativan when these measures were ineffective. Despite the physician's orders for Ativan being marked as indefinite, the CP did not request a stop date during medication reviews, and the physician did not respond to the CP's request for a risk versus benefit statement. Observations and interviews revealed that the CP did not follow through to ensure a stop date was provided for the PRN Ativan, which was a requirement. The facility's Pharmacy Consultant policy mandated that the CP review each resident's medication regimen monthly and report any irregularities, including the absence of a stop date, to the Director of Nursing, medical director, and prescriber. However, the CP's failure to act on this requirement placed Resident 14 at risk for complications related to the prolonged use of psychotropic medication.
Failure to Obtain Stop Dates for PRN Ativan
Penalty
Summary
The facility failed to obtain a stop date from the physician for the continued use of PRN Ativan for two residents, R14 and R25, which placed them at risk for unnecessary psychotropic medication. R14's electronic medical record documented diagnoses of anxiety disorder, vascular dementia, and recurrent major depressive disorder. The care plan for R14 included non-pharmacological interventions such as offering hand towels to fold, a baby doll or cat for distraction, and family visits. Despite these measures, the physician's order for PRN Ativan was marked indefinite, and the consultant pharmacist's medication reviews did not request a stop date, leading to the continued use of the medication without a specified duration. R25's electronic medical record documented diagnoses of heart failure, macular degeneration, and chronic pain, with a severely impaired cognition score. The care plan directed staff to introduce themselves and explain care procedures due to R25's poor eyesight. The physician's order for PRN Ativan did not include a stop date, and the facility's policy required a 14-day limit unless the prescriber documented a rationale for extension. The absence of a stop date for R25's PRN Ativan placed the resident at risk for unnecessary psychotropic medication. Observations revealed that R14 exhibited behaviors such as pulling on a phone wire and removing shoes and socks, while R25 required assistance with mobility. Administrative Nurse D confirmed that the PRN Ativan orders should have included a stop date, as per the facility's policy. The failure to obtain a 14-day stop date or a physician rationale for the continued use of PRN Ativan for both residents resulted in a deficiency related to the management of psychotropic medications.
Failure to Maintain Sanitary Food Preparation
Penalty
Summary
The facility failed to prepare food in a sanitary manner for two residents who requested a lettuce salad at mealtime. During an observation, Dietary Staff (DS) CC was seen placing gloves on her hands and handling a head of lettuce. After unwrapping the lettuce and removing the core, DS CC lifted the trash can lid to dispose of the discarded lettuce without changing gloves. She then returned to the lettuce, chopped it, and placed it into bowls without changing her gloves, which had been contaminated by touching the trash can lid. Upon inquiry, DS CC admitted to not changing her gloves after touching the trash can lid. DS BB, another staff member present, took the contaminated bowls of lettuce and placed them in the refrigerator, intending to serve them to residents. When questioned about serving the contaminated lettuce, DS BB removed the lettuce from the refrigerator and washed it in the sink before placing it back into bowls. The facility's Food Preparation and Handling policy requires gloves to be changed and hands washed between preparation of different food items and after contamination by potentially soiled surfaces. This failure placed the two residents at risk for foodborne illness.
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What surveyors actually found near you
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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.
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Nursing homes near Stockton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Redbud Village | 14.5 mi | — | 2 | 0 |
| Phillips County Retirement Center | 22.4 mi | ★★★★★ | 11 | 0 |
| Logan Manor Community Health Services | 22.7 mi | ★★★★★ | 19 | 0 |
| Parkview Health And Rehabilitation Center | 30.8 mi | ★★★★★ | 38 | 0 |
| Dawson Place | 30.8 mi | ★★★★★ | 17 | 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.