Solheim Senior Community

In the surveyor’s words

From the most serious findings on record at Solheim Senior Community, in the surveyor’s own words.

• Actual harm, isolatedF689Nov 14, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF550Dec 18, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF677Dec 18, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF686Dec 18, 2025

  Based 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. Findings:1. […]

• No harm, potential for more than minimal, patternF804Dec 18, 2025

  Based 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.Findings: 1. […]