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Citation history
Health deficiencies cited at Solheim Senior Community during CMS and state inspections, most recent first.
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.
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.
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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 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 | — | 15 | 0 |
| College Vista Post-acute | 0.6 mi | — | 0 | 0 |
| Glendale Adventist Medical Center Dp/snf | 1 mi | — | 0 | 0 |
| Ararat Post Acute | 1.1 mi | — | 20 | 0 |
| Glendale Post Acute Center | 1.4 mi | — | 23 | 0 |
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