Solomon Valley Manor

Inspectors wroteThe facility had a census of 29 residents, with 12 sampled, including six reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide adequate supervision and identify and implement interventions to prevent falls for Resident (R) 24 and R23, who had falls resulting in major injuries. This placed the residents at the risk of ongoing falls and injuries.

Inspectors wroteThe facility had a census of 29 residents. The sample included 12 residents with two residents reviewed for nutrition. Based on observation, record review, and interview, the facility failed to recognize Resident (R) 23's weight loss and act upon the Registered Dietician (RD) recommendation to prevent further loss. This resulted in a significant unintended weight loss of 9.74 percent in three months and placed the resident at risk for complications related to continued weight loss.

Inspectors wroteThe facility had a census of 29 residents. The sample included 12 residents. Based on the interview and record review the facility lacked evidence the required committee members, including the Medical Director, attended the Quality Assurance Performance Improvement (QAPI) meetings quarterly. This placed the residents who resided in the facility at risk for decreased quality of care.

Inspectors wroteThe facility had a census of 29 residents. The sample included 12 residents of which one resident was reviewed for hospitalizations. Based on observation, record review, and interview, the facility failed to provide Resident (R) 28 with a bed hold policy as required. This placed the resident at risk of being unable to return to the facility in the same room or bed.

Inspectors wroteThe facility had a census of 29 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to review and revise Resident (R) 23's care plan with resident-centered intervention to prevent R23's falls and R24's care plan to prevent pressure ulcers. This placed R24 and R23 at risk for further falls and injuries related to uncommunicated care needs.

Inspectors wroteThe facility had a census of 29 residents. The sample included 12 residents of which three were reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to provide interventions to prevent a facility-acquired pressure ulcer to Resident (R) 23's heel upon her significant change in mobility. The facility further failed to ensure all interventions were implemented as directed to prevent wound worsening or promote healing. This placed the resident at risk of complications related to skin breakdown and wounds.

Inspectors wroteThe facility had a census of 29 residents. The sample included 12 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to ensure the Consultant Pharmacist (CP) identified and reported that Resident (R)14 lacked a stop date as required by the Center for Medicare and Medicaid Services (CMS) for the continued use of as-needed (PRN) Ativan (antianxiety medication). This placed R14 at risk for complications related to psychotropic (alters mood or thought) medication use beyond 14 days.

Inspectors wroteThe facility had a census of 29 residents. The sample included 12 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to obtain a stop date from the physician for the continued use of as-needed (PRN) Ativan (antianxiety Medication) for two residents, Resident (R) 14 and R25. This placed the residents at risk for complications related to psychotropic (alters mood or thought) medications and unnecessary medication.

Inspectors wroteThe facility had a census of 29 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to prepare food in a sanitary manner for two residents who requested a lettuce salad at mealtime. This placed the residents at risk for foodborne illness.

Inspectors wroteThe facility had a census of 28 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to store food in accordance with professional standards for food service safety for the 28 residents who resided in the facility and received their food from the facility kitchen, when the facility failed to label and date freezer food items and failed to defrost a freezer. This placed the 28 residents at risk for foodborne illness.

Inspectors wroteThe facility had a census of 28 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to provide and promote dignity for Resident (R) 14 who had a indwelling catheter (a tube in bladder). This placed the resident at risk for embarrassment and impaired psychosocial wellbeing.

Inspectors wroteThe facility had a census of 28 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to provide foot care and services for Resident (R)13 which placed R13 at risk for pain in feet, and decreased mobility and quality of life.

Inspectors wroteThe facility had a census of 28 residents. The sample included 12 of which three residents were reviewed for pain. Based on observation, record review and interview the facility failed to recognize, evaluate, manage and treat the underlying cause of pain for Resident (R) 13. This placed the resident at risk for impaired mobility and diminished her quality of life.

Inspectors wroteThe facility reported a census of 29 residents. The sample included 12 residents with two reviewed for accidents and hazards. Based on observation, record review, and interview, the facility failed to ensure a safe, hazard free environment for Resident (R) 27, who had severe cognitive impairment and poor safety awareness. She was independently mobile and had a history of wandering throughout the facility. On 09/04/21 at 08:25 PM, R27 wandered into the facility kitchen through an unlocked door. While in the kitchen, with no facility staff present, R27 fell between the counter and the stove. She sustained a small cut to the finger as well as abrasions on her back. The unlocked kitchen door allowed R27 and four other residents who wandered open access to a stove, multiple knives stored in the kitchen prep area as well as unsecured chemicals. [...]

Inspectors wroteThe facility had a census of 29 residents. The sample included 12 residents. Based on observation, interview and record review, the facility failed to provide sanitary service during two meals in one of one facility dining rooms.

Inspectors wroteThe facility had a census of 29 residents. The sample included 12 residents of which one was reviewed for activities of daily living (ADLs). The facility failed to perform 72-hour voiding diary on admission and failed to provide Resident (R) 29 with a toileting plan for incontinence when the resident was aware of the need to urinate.