Solomon Valley Manor

The 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. Findings included: - The facility's sign-in sheets for the QAPI meetings documented that the meetings were held quarterly but lacked evidence of the medical director's attendance for the period of May through September 2024. On 10/24/24 at 01:49 PM, Administrative Staff A verified the facility's medical director did not attend a QAPI meeting in the third quarter of 2024. The facility did not provide a policy. The facility failed to ensure the medical director attended QAPI meetings at least quarterly which placed residents at risk of decreased quality of care.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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. Findings included: - R28's Electronic Medical Record (EMR) included diagnoses of anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), major depressive disorder (major mood disorder that causes persistent feelings of sadness), heart failure, disorder of bone, localized edema (swelling resulting from an excessive accumulation of fluid in the body tissues), acute kidney failure, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and bradycardia (low heart rate, less than 60 beats per minute). The Minimum Data Set (MDS) dated [DATE],…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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. Findings included: - R23's Electronic Medical Record (EMR) documented that R23 had diagnoses of a need for assistance with personal care, hyperproteinemia (abnormally high level of protein in the blood), hypertension (HTN-elevated blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), insomnia (inability to sleep), delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), dementia (a progressive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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. Findings included: - R23's Electronic Medical Record (EMR) documented that R23 had diagnoses of a need for assistance with personal care, hyperproteinemia (abnormally high level of protein in the blood), hypertension (HTN-elevated blood pressure), anxiety (mental or emotional reaction characterized by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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. Findings included: - R14'sElectronic Medical Record documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), and recurrent major depressive disorder (MDD- mood disorder which causes persistent feelings of sadness). The Quarterly Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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. Findings included: - R14'sElectronic Medical Record documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), and recurrent major depressive disorder (MDD- mood disorder which causes persistent feelings of sadness). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R14 had short- and long-term memory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The 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. Findings included: - On 10/24/24 at 11:55 AM, observation revealed Dietary Staff (DS) CC placed gloves on her hands and took a head of lettuce out of the refrigerator. DS CC then unwrapped the plastic wrap, and several layers of lettuce leaves, took the core out of the center, then went to the trash can, lifted the trash can lid, and threw away the discarded lettuce. DS CC then returned to the lettuce without changing gloves, chopped several small servings of lettuce, and placed the chopped lettuce into two small bowls. Upon inquiry, DS CC stated she had not changed her gloves following touching the trash can lid and preparing the lettuce. DS BB, who was also present, then took the two bowls, covered them with foil, and placed the bowls into the refrigerator. Upon questioning DS BB on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The 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. Findings included: - On 04/20/23 at 09:31 AM, observation in the kitchen dry storage room, revealed a silver freezer which had an unlabeled, undated loaf of banana bread wrapped in tin foil and an unlabeled, undated paper plate with cookie bars. On 04/20/23 at 09:31 AM, Certified Dietary Manager (CDM) BB verified the above finding, discarded the food items, and stated staff should label and date all food items stored in the freezer. On 04/24/23 at 10:30 AM, observation in the kitchen dry storage room revealed the white upright freezer had approximately one-half inch (in) of ice on four shelves extending from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The 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. Findings included: - R14's Electronic Medical Record (EMR) documented diagnoses of urinary retention (difficulty urinating and completely emptying the bladder). The Quarterly Minimum Data Set (MDS) dated 03/19/23, documented the resident required extensive assistance with bed mobility, transfers and had a urinary catheter. The updated Urinary Catheter Care Plan, dated 03/30/23, instructed the staff to keep the urinary drainage bag covered. On 04/20/23 at 10:50AM, observation revealed R14 lying in bed. Further observation revealed a urinary drainage bag hanging on the side of the bed uncovered. On 04/24/23 at 09:48AM, observation revealed R14 lying in bed. Further observation revealed a urinary drainage bag hanging on the side of the bed uncovered. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The 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. Findings included: - The Electronic Medical Record (EMR) documented R13 had diagnoses of osteoporosis (a condition in which bones become weak and brittle), Alzheimer's disease (a disease that destroys memory and other mental functions),and venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes). The Annual Minimum Data Set (MDS), dated 01/29/23, documented the resident had a Brief Interview for Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented R13 used a cane and required stand by assistance with ambulation. She had pain present and constant daily which limited daily activities. The Care Area Assessment Summary (CAA) for pain, dated 02/02/23, documented R13 had moderate pain to the bottom of her feet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The 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. Findings included: - The Electronic Medical Record (EMR) documented R13 had diagnoses of osteoporosis (a condition in which bones become weak and brittle), Alzheimer's disease (a disease that destroys memory and other mental functions),and venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes). The Annual Minimum Data Set (MDS), dated 01/29/23, documented the resident had a Brief Interview for Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented R13 used a cane and required stand by assistance with ambulation. She had pain present and constant daily which limited daily activities. The Care Area Assessment Summary (CAA) for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The 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. Findings included: - On 09/13/21 at 11:52 AM, observation during the noon meal revealed Dietary Staff (DS) CC served residents beverages and touched rim or lip surface while handling the glasses. DS CC moved one resident's wheelchair for her, and then continued serving other residents' beverages, touching the lip surface with contaminated hands. Continued observation revealed DS CC unwrapped a straw and handled it with bare contaminated hands when putting it in the resident's glass. On 09/16/21 at 11:47 AM, observation in the dining room revealed DS DD used a cloth to wipe the floor using his foot to push it around. DS DD picked up the soiled cloth with bare hands, put it on the bottom of the beverage cart, and continued serving residents beverages without washing his hands. Further observation during the meal revealed DS BB handled residents' glasses very…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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. Findings included: - The Physician Order Sheet (POS), dated 07/06/21, documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), and hypothyroidism (a condition characterized by decreased activity of the thyroid gland). The admission Minimum Data Set (MDS), dated [DATE], documented the resident's Brief Interview for Mental Status (BIMS) score of 13 indicated intact cognition. The assessment documented the resident required one to two staff extensive assistance for all activities of daily living except for eating which he was independent. The assessment documented the resident was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.