Solon Nursing Care Center

In the surveyor’s words

From the most serious findings on record at Solon Nursing Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF886Feb 21, 2022

  Based on clinical record review, staff interview and physician interview, the facility failed to regularly test staff and 2 of 2 residents who tested positive for COVID-19 and expired (Residents #42 and #258). The failure included not conducting routine testing of unvaccinated staff members per Community Transmission Levels which would have required twice a week testing from [DATE] thru [DATE]. The failure included not conducting Broad Based, Facility Wide Testing of all staff and residents in lieu of sufficient evidence of close contact tracing when positive cases arose on [DATE] and [DATE]. The failure to conduct routine testing of staff and residents resulted in an Immediate Jeopardy to the health, safety, and security of the residents. […]

• Immediate jeopardy, patternF689Feb 21, 2022

  Based on observations, clinical record review, and staff interviews, the facility failed to appropriately supervise and intervene to prevent one of three resident reviewed from eloping from the facility (Resident # 18). The facility staff failed to ensure the location of the residents in the Chronic Confusion Dementing Illness (CCDI) unit before turning off the door alarms. This failure resulted in an Immediate Jeopardy to the health, safety, and security of the resident. The facility reported a census of 55 residents. Findings Include: Resident #18's Minimum Data Set (MDS) Assessment completed 12/9/21, identified diagnoses of non-Alzheimer's dementia, and heart failure. […]

• Immediate jeopardy, isolatedF888Feb 21, 2022

  Based on clinical record review, facility record review, and staff interview, the facility failed to develop and implement any policies or procedures related to staff receiving a COVID-19 vaccination and failed to identify additional precautions to be taken by unvaccinated staff. The facility failed to ensure 100% of staff received the vaccine as the facility reported an overall vaccination rate of 95.6%. The facility experienced an outbreak of COVID-19 infection during the month of [DATE] which resulted in 2 resident deaths with the primary cause of death documented as COVID-19 (Resident #42 and #258). This failure led to an immediate jeopardy situation. The facility reported a census of 55 residents. Findings Include: 1. […]

• Actual harm, isolatedF689Apr 1, 2024

  Based on observation, clinical record review, facility investigation report, and staff interviews, the facility failed to supervise one of four residents reviewed in order to prevent a fall with major injury (Resident #2). The facility reported a census of 67 residents. Findings include: The MDS (Minimum Data Set) dated 10/19/2023 revealed Resident #2 had moderately impaired cognitive abilities, required moderate assistance to transfer from one surface to another, use the toilet, and dress. The resident required supervision with eating, had urinary and bowel incontinence, and a fall resulting in a fracture. The MDS reported the resident had diagnoses including stroke, coronary artery disease, hypertension, dementia, and repeated falls. […]

• Actual harm, isolatedF686Dec 1, 2022

  Based on clinical record review, facility staff, Nurse Practitioner, Wound Clinic Doctor and family member interviews, the facility failed to prevent the development of a pressure ulcer to the right heel for one of one residents reviewed which resulted in a serious infection and partial amputation of the heel (Resident #4). The facility reported a census of 57 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 4 out of 15, and with the following diagnoses: Deep Vein Thrombosis (DVT - blood clots), renal insufficiency (kidney failure) and arthritis. […]