Solheim Senior Community

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity and respect for five (5) of five sampled residents (Resident 55, 39, 27, 28 and 67) reviewed for dignity care area when:1. Resident 55's clothes had brownish to blackish stain on the resident's shirt and black, ash-like fibers on the chest area.2. Resident 39's clothes had a brownish stain on her shirt. 3. Certified Nursing Assistant 1 (CNA 1) used labels when addressing Resident 27 during breakfast on 12/16/2025.4. Resident 28's clothes had strands of white hair and dried whitish and yellowish material on the chest and shoulder areas.5. Resident 67's activities of daily living (ADLs-fundamental self-care tasks performed daily, like bathing, dressing, eating, using the toilet, and moving around) were not provided timely. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (2) of 2 sampled residents (Resident 55 and 39) reviewed for Activities of Daily Living (ADLs, are activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) were provided care and services to maintain good grooming and personal hygiene when:1. Resident 55's fingernails on both hands were long, untrimmed and had blackish brown discolorations.2. Resident 39's fingernails on both hands were long, untrimmed and had brownish discolorations. This deficient practice had the potential for Resident 55 and 39 to develop infection and skin breakdown which could result in the decline of the residents' wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement treatment for the prevention of pressure ulcer (PU, painful wound caused as a result of pressure or friction) by failing to ensure that the low air loss mattress (LALM, mattress used for residents who are at risk for developing sores or already have pressure ulcer designed to circulate a constant flow of air for the management of pressure sores) was on the correct settings for two (2) of two sampled residents (Residents 24 and 37) under pressure ulcer care area, in accordance with the facility's policy and procedure (P&P) and physician's order. This deficient practice had the potential for Residents 24 and 37 to develop pressure ulcers.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure the food was prepared by methods that conserved the flavor, was palatable and served at a safe and appetizing temperature for five of five (Residents 2, 56, 13, 28, and 34) sampled residents during lunch time. This deficient practice had the potential to impact on the residents' nutritional status and quality of life, and can lead to insufficient food intake that could potentially lead to weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food storage handling practices in accordance with its policy and procedure (P&P) by failing to ensure food was labeled and discarded after its use by date. These deficient practices had the potential to result in food born illness (any sickness that is caused by the consumption of foods or beverages that are contaminated with certain infectious or noninfectious agents) to 64 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of two garbage containers (dumpster) lids remained closed as indicated in the facility's policy and procedure (P&P) titled, Garbage Disposal & Waste Management,. This failure had the potential to result in the attraction and spread of vermin (animals that are believed to be harmful, or that carry diseases, e.g., rodent's parasitic worms or insects) that could potentially enter the facility and spread diseases to the residents. During an observation on 12/16/2025 at 1:53 PM in the facility's alley dumpsters area, there were two dumpsters (one Black and one blue) with lids left open. In addition, the black dumpster area gate was not closed. During an observation on 12/18/2025 at 8:24 AM in the facility's alley dumpsters area, the black dumpster was observed with lids open exposing the contents inside. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and/or disease in the healthcare setting) were followed for two (2) of five (5) sampled residents under the infection control area in accordance with the facility's policy and procedure when:1 Resident 56's nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was found connected to the breathing treatment machine (turns liquid medicine into a fine, breathable mist [aerosol] that is inhaled directly into the lungs through a mouthpiece or mask) was not stored in a clean bag, labeled with resident's name and date of first use and left hanging in between the nightstand and the curtain close to the floor area. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's Antibiotic Stewardship Program (coordinated interventions designed to improve and measure the appropriate use of antibiotic agents by promoting the selection of the optimal drug regimen including dosing, duration of therapy, and route of administration) for the antibiotic (medication used to treat infection) use for two (2) of three (3) sampled residents (Residents 26 and 68) by failing to:1. Ensure Resident 26's laboratory test was done such as culture (test to check for bacteria or yeast, helping identify the specific germs causing infection, and find the best antibiotic to treat it) and sensitivity (a medical laboratory test identifying germs [like bacteria or fungi] causing the infection, in a sample and the best antibiotics to kill them) to ensure the appropriate use of antibiotic. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call light (used in healthcare facilities as an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for three (3) of four sampled residents (Resident 55, 36, and 33) as indicated in the facility's policy and care plan. This deficient practice had the potential not to meet Resident 55, 36 and 33's needs and preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a comfortable sound level (sound that does not interfere with resident's hearing and enhance privacy when privacy is desired, and encourage interaction when social participation is desired, resident's control over unwanted noise) for one of twenty sampled residents (Resident 31). This deficient practice had the potential to negatively impact Resident 31's quality of life. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately monitor the fluid intake for one of one sampled resident (Resident 33) under hydration care area. This deficient practice had the potential to cause fluid overload (when the body has too much water, causing fluid to build up in blood vessels and tissues, leading to swelling, high blood pressure, shortness of breath, and increased strain on the heart and kidneys) and/or increase edema ( swelling caused by excess fluid trapped in the body's tissues and shortness of breath).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide interventions to prevent accidents (any unexpected or unintentional incident, which results or may result in injury or illness) such as for aspiration (happens when food, liquid, or other material enters a person's airway and eventually the lungs by accident) and/ or choking (when food or another object gets stuck in your airway) for one (1) of seven sampled residents (Resident 39) from the accidents care area by failing to ensure Resident 39's head of the bed (HOB) was upright or elevated to 90-degree angle (a unit for measuring angles, where a full circle is 360 ) and properly positioned during mealtimes. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate and complete record for one (1) of 20 sampled residents (Resident 30) as indicated in the facility's policy and procedure. This deficient practice had the potential to result in miscommunication, improper delivery of care and inaccurate information of the care provided to the Resident, which could negatively affect the overall wellbeing of Resident 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) who was assessed as dependent with staff for Activities of Daily Living (ADL's- basic self-care tasks essential for independent living, including bathing, dressing, eating, using the toilet, and moving from place to place) and with poor ability in maintaining sitting balance was not left unattended by Certified Nurse Assistant 1 (CNA1) by turning her back from Resident 1 who was in a shower chair while in the shower room on 11/2/2025. This deficient practice resulted in Resident 1 sustaining a fall in the shower room on 11/2/2025 at around 10 AM resulting in a laceration (a deep cut or tear in the skin) to the forehead. [...]

Inspectors wroteBased on interview and record review, facility failed to develop and implement a comprehensive person-centered care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs) for one of two sampled residents (Resident 1) to address resident's poor mobility and balance per facility policy. This deficient practice resulted in Resident 1 sustaining a fall in the shower room on 11/2/2025 at around 10 AM while sitting in a shower chair. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services for two of four sampled residents (Residents 16 and 53) by failing to: 1. Administer Resident 16's diltiazem (medication for high blood pressure and angina [chest pain]) as ordered by the physician. 2. Ensure no expired medication was kept in the medication cart and medication storage room. On 10/19/2024, observed 1 expired bottle of diltiazem (Resident 16's medication), 2 bottles of buspirone (a medication that treats anxiety) and 3 bottle of Blood Sugar Check Machine Control solution (test strips used to check that the meter used to check blood sugar is working properly and is reflecting accurate results). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error (any preventable event that may cause or lead to inappropriate medication use or resident harm while the medication is in the control of the health care professional, patient) rate during medication pass observation on 10/9/2024 was not above (5) percent (%). The outcome was two (2) medication errors out of twenty-eight (28) opportunities for errors, which resulted in a Medication Administration Error Rate of 7.1%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure by failing to: 1. Label food items in the kitchen. 2. Discard expired food in the kitchen. 3. Discard dented soda can found in storage room. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its infection control policy for four (4) of 18 sampled residents (Resident 19, 60, 9 and 53) by failing to ensure: 1. 2. and 3. Staff were using a gown while providing wound care treatment to Residents 19, 60 and 9, who were on enhanced barrier precaution (EBP, an infection control practice that involves wearing gowns and gloves during high-contact activities with residents in nursing homes). 4. Staff was using a gown while administering medication via gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for residents with swallowing problems) tube to Resident 53 who was on enhanced barrier precaution. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive, resident-centered care plan (a document that outlines a resident's care goals and the activities that will be performed to achieve those goals) for resident's actual fall on 6/13/2024 and implement the care plan interventions for one of two sampled residents (Resident 44). 1. On 6/13/2024, Resident 44 was left unattended by facility staff during shower to dispose soiled clothes. 2. On 10/8/2024, Resident 44 was observed Resident 44 got up from his bed by himself, and walked to the restroom and was wearing non-skid sock (slip resistant socks designed to reduce the risk of slipping and falling on wet or slippery surfaces) on left foot and no non- skid sock on the right foot. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to address a significant unplanned weight loss of greater than five (5) % within 30 days from 9/6/2024 to 10/9/2024 for one (1) of 1 sampled Residents (Resident 62) in accordance with the facility policy. This deficient practice had the potential to cause Resident 62 to experience further weight loss and complications such as skin breakdown, malnutrition (faulty nutrition due to inadequate or unbalanced intake of nutrients), and weakness affecting the resident's over all well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer the correct oxygen level for one (1) of 1 sampled resident (Resident 16) in accordance with physician's order. These deficient practices had the potential to cause Resident 16 to experience shortness of breath (SOB) and desaturation (low oxygen level).

Inspectors wroteBased on interview, and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 53) was free from unnecessary use of psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure by failing to ensure Resident 53 has the specific target behavior and indication for the use and monitoring of quetiapine (Seroquel, to treat certain mental/mood disorders). This deficient practice had the potential to place Resident 53 at risk for significant adverse (harmful) consequences from the use of unnecessary psychotropic drug, which could result to impairment or decline in the residents' mental, physical condition, functional, and psychosocial status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Resident 53's medication bottle for sucralfate (to prevent ulcers [open sores]) was labeled in accordance with doctor's orders and included the appropriate cautionary instructions regarding administration route. This deficient practice had the potential to harm Resident 53 due to potential dispensing and administration errors (incorrect route) and can possibly lead to adverse side effects, aspiration, and/ or death. 2. Resident 16's expired diltiazem (treats high blood pressure and prevents chest pain) was not stored in the facility's medication cart. This deficient practice had the potential for harm to Resident 16 due to the potential loss of strength of the drug, and for the residents to not receive the full effect of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement treatment for the prevention of pressure ulcer (painful wound caused as a result of pressure or friction) by failing to ensure that the low air loss mattress (LAL, mattress used for residents who are at risk for developing sores or already have pressure sores designed to circulate a constant flow of air for the management of pressure sores) was on the correct settings for three (3) of 3 sampled residents (Residents 30, 36, and 38) in accordance with physician's order and facility policy. This deficient practice had the potential to place the residents at risk for skin integrity complications and pressure injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure they do not have a medication error rate of five percent (%) or greater as evidenced by eight (8) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services) out of 26 opportunities (observed administered medications) for error and yielded a medication error rate of 30.77 percentage (%), for one of six sampled residents (Residents 64) observed during medication administration (Med Pass). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility's policy and procedure on storage and disposal of medication for one of two medication storage rooms. There were three (3) unopened straight catheters (a soft, thin tube used to pass urine from the body) with expiration date of 2/1/2022, 3 boxes of insulin syringes (a medical instrument that is expressly designed to administer insulin [a hormone that lowers the level of glucose {a type of sugar} in the blood] into the body via injection) with expiration date of 11/8/2022, four (4) boxes of Brand 1 lancets (needle that is used to obtain blood for testing blood sugar) with expiration date of 5/31/2023, 3 boxes of brand 2 lancets with expiration date of 7/2023, one (1) bottle of Brand 1 blood sugar test strip (an easy way to test your blood sugar, strips work with glucose meters to read your [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: a. Label foods in the kitchen with item names, open date and/or receive date, and expiration date or use by date, and failed to discard expired foods from food storage and walk in refrigerator. b. Monitor and clean the ice machine. c. Ensure there was an air gap (an unobstructed vertical space between the water outlet and the flood level of a plumbing fixture) for a drainage pipe and not touching the kitchen floor. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident was informed in advance, of the care to be furnished and the type of professional who will furnish care for one of seventeen residents (Resident 19) based on the facility policy. This deficient practice has resulted not honoring Resident 19's right to be informed and choose the option she prefers for her ancillary care.

Inspectors wroteb) A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE] and re- admitted on [DATE]. The admission Record indicated, Resident 2's with diagnoses which included Diabetes Mellitus (DM, a condition that happens when your blood sugar [glucose] is too high), Functional quadriplegia (FQ, the complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord) and hypertension (HTN, high blood pressure) A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 9/5/2023, indicated Resident 2 has intact cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. [...]

Inspectors wroteBased on interview and record review, the facility failed notify the doctor for a severe weight loss and Registered Dietician (RD) recommendation on 9/22/2023 for one (1) of 3 sampled residents (Resident 5). This deficient practice placed Resident 5 at risk for further decline in nutritional status and continued weight loss.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan to reflect the use of oxygen one (1) of 17 sampled residents (Resident 221) in accordance with the facility policy and procedure. This deficient practice placed Resident 221 at risk for not having her needs met which had the potential to negatively affect resident's well-being.

Inspectors wroteBased on interview and record review the facility failed to revise the comprehensive care plan for one of one sampled residents (Resident 36) as indicated on the facility's policy. This deficient practice had the potential for Resident 36 to not receive specific interventions to prevent decline in functional ability.

Inspectors wroteBased on interview and record review, the facility failed to ensure four (4) out of 17 sampled residents (Resident 26, 7, 66 and 54) receive assistance with toileting on a timely manner. This deficient practice resulted in the residents feeling frustrated and embarrassed due to delay in receiving care and had the potential to lead to skin breakdown and urinary tract infection (UTI, an infection of the bladder and urinary system).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and modify interventions, consistent with the resident's assessed needs, choices, and preferences to maintain acceptable parameters of nutritional status for two of three sampled residents (Resident 60 and Resident 5) a. The facility failed to implement interventions to prevent weight loss for Resident 5. The resident experienced a weight loss of 19 pounds (lbs., unit of measurement. Severe weight loss if there is loss greater than 5 % in one month) in one month. b. The facility failed to implement interventions for gradual weight loss such as to assist Resident 60 with hand feeding. Resident 60 was observed with untouched food tray on 10/4/2023. This deficient practice placed Resident 60 and Resident 5 at risk for further decline in nutritional status and continued weight loss.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure for one of six sampled residents (Residents 64) was free from significant medication error (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications [not recommendations] regarding the preparation and administration of the medication or biological; or accepted professional standards and principles) by failing to administer seven (7) medication due to be given at 9 AM in accordance with the physician's order. The following medications for Resident 64 were administered more than one (1) hour from the scheduled administration time: 1. Acetazolamid e (treats swelling caused by heart disease) 125 milligram (mg, unit of measurement) tablet daily, administer 1 tablet by mouth daily. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: a. Follow infection control measures in the kitchen when a dirty white towel, dish sponge, spatula, and three containers were found on the floor and moldy tomatoes were found in the walk-in refrigerator. b. Follow infection control measures for oxygen administration by having the oxygen tubing laying on the floor while the Resident 19 is on oxygen therapy on 10/4/2023. These deficient practices resulted in contamination of kitchen items and placed the residents at risk for infection. In addition, these deficient practices resulted in potential for introducing bacteria that might cause respiratory tract infection (any infectious disease of the upper or lower respiratory tract) for Resident 19.