Solomon Valley Manor

In the surveyor’s words

From the most serious findings on record at Solomon Valley Manor, in the surveyor’s own words.

• Immediate jeopardy, patternF689Sep 16, 2021

  The 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. […]

• Actual harm, isolatedF689Oct 24, 2024

  The 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. Findings included: - R23's Electronic Medical Record (EMR) documented 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… […]

• Actual harm, isolatedF692Oct 24, 2024

  The 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. […]

• No harm, potential for more than minimal, widespreadF868Oct 24, 2024

  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. […]

• No harm, potential for more than minimal, widespreadF812Apr 26, 2023

  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. […]