Inspection Reports for Solon Nursing Care Center
523 East Fifth Street, IA, 523339620
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 3, 2025 found the facility to be in substantial compliance with no deficiencies cited. Earlier inspections generally showed a pattern of substantial compliance, though prior reports identified deficiencies related mainly to resident supervision, fall prevention, call light responsiveness, infection control, and care plan adherence. Complaint investigations were mostly unsubstantiated, with a few substantiated cases involving inadequate supervision leading to falls and issues with pain management and infection prevention. Enforcement actions such as a discretionary denial of payment occurred in 2022, but no fines or license suspensions were listed in the available reports. The facility’s inspection history indicates improvement over time, with recent surveys showing compliance following correction of earlier deficiencies.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
6.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
41% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
66 residents
Based on a April 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 3, 2025
Visit Reason
An annual recertification survey and investigations of complaint #129641-C and facility reported incidents #128808-I and #129477-I were conducted from June 30, 2025 to July 3, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigations of complaint #129641-C and facility reported incidents #128808-I and #129477-I were conducted.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 24, 2025
Visit Reason
An investigation for complaint #127820-C and facility reported incident #127821-I was conducted from April 21, 2025 through April 24, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation was related to complaint #127820-C and facility reported incident #127821-I; the facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 14, 2025
Visit Reason
A complaint investigation for complaints #124146-C and 124819-C was conducted from December 30, 2024 to January 14, 2025.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Complaint Details
Investigation was related to complaints #124146-C and 124819-C and the facility was found to be in substantial compliance.
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 25, 2024
Visit Reason
An annual recertification survey and investigation of complaints #120480-C and #121538-C were conducted from July 22, 2024 to July 25, 2024.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation of complaints #120480-C and #121538-C was conducted during the survey.
Inspection Report
Re-Inspection
Census: 66
Deficiencies: 0
Apr 25, 2024
Visit Reason
A revisit of the survey ending April 1, 2024 and investigation of facility reported incident #120413-I was conducted.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective April 11, 2024. The facility reported incident #120413-I was not substantiated.
Complaint Details
Facility reported incident #120413-I was not substantiated.
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
Mar 26, 2024
Visit Reason
The inspection was conducted as a result of facility reported incidents #116186-I and #117507-I between March 26, 2024 and April 1, 2024 to investigate allegations related to resident safety and supervision.
Findings
The facility failed to supervise Resident #2 adequately to prevent a fall resulting in a major injury. The investigation revealed multiple falls, inadequate staff response to call lights, and staff disciplinary actions related to failure to respond. The resident had a history of falls and cognitive impairment, and the facility implemented corrective actions including staff re-education and call light system improvements.
Complaint Details
The investigation was based on facility reported incidents #116186-I (substantiated) and #117507-I (not substantiated).
Deficiencies (1)
| Description |
|---|
| Failure to ensure the resident environment was free of accident hazards and to provide adequate supervision to prevent falls, resulting in a major injury to Resident #2. |
Report Facts
Resident census: 67
Falls: 15
Completion date: Apr 11, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Registered Nurse | Named in failure to respond to call light and supervision findings |
| Staff B | Director of Nursing | Reported on Resident #2's call light use and supervision |
| Staff A | Administrator | Reported on call light system usage and issues |
| Staff C | Certified Nurse Aide | Observed resident prior to fall and assisted with care |
| Staff D | Certified Nurse Aide | Observed resident on floor bleeding after fall |
| Staff F | Certified Nurse Aide | Received discipline for not working assigned hall during critical time |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 7, 2023
Visit Reason
A complaint investigation was conducted for Complaints #113806-C and #115216-C and a Facility Self-Reported Incident #115238-I from September 5, 2023 through September 7, 2023.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation involved Complaints #113806-C and #115216-C and a Facility Self-Reported Incident #115238-I; the facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 16, 2023
Visit Reason
The document reflects acceptance of a credible allegation of compliance and plan of correction for the facility, leading to certification in compliance effective June 16, 2023.
Findings
The facility was found to be in compliance based on the accepted plan of correction and credible allegation of compliance.
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 8
May 25, 2023
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of Complaint #111203-C.
Findings
The facility was found deficient in multiple areas including resident dignity and rights, call light accessibility and response times, proper monitoring and assessment of wander guard devices, infection prevention with indwelling catheters, oxygen administration per physician orders, and sufficient nursing staff to respond timely to call lights.
Complaint Details
Complaint #111203-C was substantiated as part of the annual recertification survey conducted from May 22 to May 25, 2023.
Severity Breakdown
SS=D: 7
SS=E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to maintain residents' dignity for two residents related to removal of bed side rails and call light response. | SS=D |
| Failed to ensure call light was within reach for one resident. | SS=D |
| Failed to complete and transmit a discharge assessment for one resident. | SS=D |
| Failed to ensure accuracy of PASARR assessments for one resident. | SS=D |
| Failed to ensure wander guards were monitored daily for placement and functioning for four residents and failed to assess one resident after removal of wander guard. | SS=E |
| Failed to follow proper infection prevention techniques with indwelling catheters for two residents. | SS=D |
| Failed to provide oxygen according to physician orders for one resident. | SS=D |
| Failed to answer resident call lights in a timely manner for three residents. | SS=D |
Report Facts
Resident census: 62
Call light response times: 47
Call light response times: 45
Call light response times: 45
Wander guard elopement risk score: 15
BIMS score: 12
BIMS score: 7
BIMS score: 5
BIMS score: 0
BIMS score: 3
BIMS score: 8
BIMS score: 6
Oxygen liter flow: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Licensed Practical Nurse | Reported call light notification system and response expectations |
| Staff D | Registered Nurse | Reported call light response expectations and catheter care |
| Staff F | Certified Nurse Aide | Reported call light response expectations and catheter care |
| Staff G | Certified Nurse Aide | Reported call light response expectations and catheter care |
| Staff A | Certified Nurse Aide | Reported call light response expectations and catheter care |
| Director of Nursing | Director of Nursing | Provided expectations for call light response, catheter care, wander guard monitoring, and oxygen administration |
| Administrator | Administrator | Reported lack of policies on call lights and wander guard monitoring |
| Staff E | Restorative Aide | Reported checking wander guards Monday through Friday |
| Staff H | Certified Nurse Aide | Reported resident wander guard use and monitoring |
| Social Service Staff | Reported review and correction of PASRR assessments | |
| Assistant Director of Nursing | Assistant Director of Nursing | Reported expectations for PASRR accuracy |
| Maintenance Supervisor | Reported interpretation of call light device activity report |
Inspection Report
Re-Inspection
Census: 58
Deficiencies: 0
Jan 10, 2023
Visit Reason
An on-site revisit of the complaint survey ending December 12, 2022, and an investigation of Complaint #109585-C, Facility Self-Reported Incidents #109762-I, #109982-I, #109985-I, and a Focused Infection Control Survey was conducted from January 4, 2023 to January 10, 2023.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective December 15, 2022. Complaint #109585-C and the Facility Self-Reported Incidents were not substantiated. The Denial of Payment was not effectuated.
Complaint Details
Complaint #109585-C was not substantiated. Facility Self-Reported Incidents #109762-I, #109982-I, and #109985-I were not substantiated.
Report Facts
Census: 58
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 8
Dec 1, 2022
Visit Reason
Investigation of multiple complaints and facility self-reported incidents related to involuntary discharge, care plan revisions, and other compliance issues.
Findings
The facility was found deficient in multiple areas including failure to follow involuntary discharge procedures, failure to update care plans timely, failure to follow physician orders, failure to document assessments per fall protocol, failure to prevent a pressure ulcer resulting in amputation, failure to adequately manage pain, and failure to maintain heat registers in resident rooms.
Complaint Details
The visit was triggered by multiple complaints (#107805-C, #108518-C, #108657-C, #109039-C, #109070-C) and facility self-reported incidents (#107531-I, #108300-I). Complaints #107805-C, #109039-C, and #109070-C were substantiated.
Severity Breakdown
SS=D: 6
SS=G: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to follow facility processes and state rules related to an involuntary discharge for Resident #6. | — |
| Failure to update care plans timely for Residents #2 and #9 after significant incidents. | SS=D |
| Failure to follow physician orders for Residents #8 and #9. | SS=D |
| Failure to document assessments per fall protocol for Resident #5. | SS=D |
| Failure to document assessments of skin surrounding the stoma after multiple colostomy bag changes for Resident #9. | SS=D |
| Failure to prevent development of a pressure ulcer to the right heel for Resident #4 resulting in serious infection and partial amputation. | SS=G |
| Failure to assess and intervene for pain management for Resident #9. | SS=D |
| Failure to properly maintain heat registers in resident rooms to prevent injuries for Residents #3 and #4. | SS=D |
Report Facts
Deficiencies cited: 8
Resident census: 57
Pressure ulcer size: 8
Pressure ulcer size: 8
Pain medication administrations: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff N | Registered Nurse | Reported issues with colostomy evaluation and pain documentation for Resident #9. |
| Staff J | Licensed Practical Nurse | Reported fall protocol and care plan update issues. |
| Staff A | Licensed Practical Nurse | Reported Resident #4's wound care and heat register injury. |
| Staff D | Licensed Practical Nurse | Reported care plan and wound assessment responsibilities. |
| Staff G | Wound Care Physician | Reported pressure ulcer preventability and hospital referral. |
| Hospice Nurse | Reported pain management and colostomy care issues for Resident #9. | |
| Pharmacist | Reported no communication regarding Stomahesive spray and medication order issues. | |
| Director of Nursing | DON | Reported on involuntary discharge, care plan updates, pain assessment, and colostomy evaluation. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 1, 2022
Visit Reason
A complaint investigation for Complaint #104631-C and a Facility Self-Reported Incident #104710-I was conducted from May 26, 2022 to June 1, 2022.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Complaint Details
Complaint #104631-C was investigated and found to be in substantial compliance.
Inspection Report
Re-Inspection
Deficiencies: 0
May 25, 2022
Visit Reason
An onsite revisit was conducted May 19-25, 2022 regarding a Recertification Survey and investigation of multiple complaints and facility self-reported incidents completed January to February 2022, as well as review of a complaint survey conducted April 5-12, 2022.
Findings
The facility was determined to be in substantial overall compliance effective April 27, 2022. A Discretionary Denial of Payment for New Admits was effectuated March 23 - April 26, 2022.
Complaint Details
The revisit was related to investigations of multiple complaints (#101386-C, #101664-C, #101911-C, #102589-C, #103395-C, #103342-C, #102948-C, #103705-C, #103704-C) and facility self-reported incidents (#101238-I, #101937-I).
Report Facts
Complaint numbers investigated: 9
Facility self-reported incidents investigated: 2
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 2
Apr 12, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on complaints #102948-C, #103342-C, #103395-C, #103704-C, and #103705-C from April 5 to April 12, 2022, which were substantiated.
Findings
The facility failed to ensure proper pain management for a resident with a pelvic fracture, resulting in episodes of uncontrolled pain due to failure to administer ordered pain medication timely. Additionally, the facility failed to maintain infection control by not keeping an indwelling catheter tubing/bag off the floor for another resident, increasing the risk of urinary tract infections.
Complaint Details
Complaints #102948-C, #103342-C, #103395-C, #103704-C, and #103705-C were investigated and substantiated.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to administer pain medication as ordered resulting in episodes of uncontrolled pain for Resident #9. | — |
| Failure to ensure indwelling catheter tubing/bag was kept off the floor for Resident #8, risking infection. | SS=D |
Report Facts
Resident census: 51
Pain medication doses missed: 3
Pain medication doses given: 4
Urinalysis bacteria count: 100000
Antibiotic treatment duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Licensed Practical Nurse (LPN) | Named in failure to administer pain medication to Resident #9 and disciplinary action |
| Staff K | Licensed Practical Nurse (LPN)/acting Director of Nursing (DON) | Reviewed Emergency Medication Kit, verified medication delivery, and disciplinary action |
| Staff G | Registered Nurse (RN) | Reviewed medication cart and reported on medication orders and pain management |
| Staff A | Licensed Practical Nurse (LPN) | Reported on medication order process and pain management |
| Staff D | Certified Nurse Aide (CNA) | Reported resident's pain behaviors |
| Staff I | Registered Nurse (RN) | Reported on pain medication effectiveness and monitoring |
| Staff L | Certified Nurse Aide (CNA) | Reported resident's pain behaviors |
Inspection Report
Census: 55
Deficiencies: 10
Feb 21, 2022
Visit Reason
The inspection was conducted as a Recertification Survey and investigation of multiple complaints and self-reported incidents.
Findings
The facility was found deficient in multiple areas including residents' rights to receive visitors during COVID-19, advanced directives documentation, medication administration standards, quality of care including fall assessments, supervision to prevent elopement, infection prevention and control, COVID-19 testing and vaccination compliance, and staff abuse training.
Severity Breakdown
SS=D: 4
SS=K: 1
SS=E: 3
SS=L: 1
SS=J: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to permit visitors as allowed during positive COVID-19 cases. | — |
| Failed to document consistent advanced directive measures for one resident. | SS=D |
| Medications not administered by nurse or certified medication aide; medications left unsupervised and without pharmacy labels for 3 residents. | SS=D |
| Failed to appropriately assess and intervene for necessary care and services to maintain residents' highest practical physical well-being; failed to complete post-fall assessments. | SS=D |
| Failed to appropriately supervise and intervene to prevent elopement of a resident resulting in immediate jeopardy. | SS=K |
| Failed to ensure staff utilized proper infection control techniques including hand hygiene during meal passing and medication administration. | SS=E |
| Failed to regularly test staff and residents for COVID-19 according to guidelines, resulting in immediate jeopardy. | SS=L |
| Failed to provide documentation of COVID-19 vaccination declination forms for unvaccinated staff and resident. | SS=E |
| Failed to develop and implement policies and procedures to ensure all staff are fully vaccinated for COVID-19 and to identify additional precautions for unvaccinated staff; facility vaccination rate was 95.6%. | SS=J |
| Failed to document staff education on mandatory reporter abuse training within 6 months of hire for two new hires. | SS=D |
Report Facts
Facility census: 55
Staff vaccination rate: 95.6
Staff total: 90
Unvaccinated staff count: 4
Unvaccinated staff count: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Named in fall and medication administration deficiencies |
| Staff B | Certified Nursing Assistant | Named in visitor restriction and infection control deficiencies |
| Staff F | Certified Nursing Assistant | Named in infection control and COVID vaccination deficiencies |
| Staff H | Registered Nurse | Named in fall and COVID vaccination deficiencies |
| Staff I | Certified Nursing Assistant | Named in elopement incident |
| Staff J | Licensed Practical Nurse | Named in COVID testing deficiencies |
| Staff K | Certified Nursing Assistant | Named in fall incident investigation |
| Staff P | Licensed Practical Nurse | Named in medication administration and pain management deficiencies |
| Staff S | Licensed Practical Nurse | Named in pain management deficiency |
| Staff U | Certified Nursing Assistant | Named in COVID testing and vaccination deficiencies |
| Staff W | Dietary Aide | Named in COVID testing deficiencies |
| Staff Z | Certified Nursing Assistant | Named in elopement incident |
| Staff CC | Environmental Aide | Named in abuse training deficiency |
| Staff KK | Certified Nursing Assistant | Named in abuse training deficiency |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Aug 26, 2021
Visit Reason
The Iowa Department of Inspections and Appeals conducted a Focused Infection Control Survey in accordance with Medicare Requirements and CDC guidance.
Findings
The facility was found to be in compliance with infection control requirements during the survey conducted from 08/24/2021 to 08/26/2021.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 25, 2021
Visit Reason
The Iowa Department of Inspections and Appeals conducted an investigation in accordance with Medicare Requirements for Long Term Care Facilities, triggered by a complaint.
Findings
The facility was found to be in compliance with no deficiencies cited. The complaint reviewed (#98961) was not substantiated.
Complaint Details
Complaint #98961 was reviewed and found to be not substantiated.
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
Jul 20, 2021
Visit Reason
The inspection was conducted to investigate a facility self-reported incident (#97868) involving resident falls and related care concerns.
Findings
The facility failed to follow care plan interventions, implement new interventions, and provide adequate supervision to prevent falls for 2 of 3 residents reviewed. Multiple falls occurred with insufficient updates to care plans and inadequate staffing to supervise residents at risk of falls.
Complaint Details
The investigation related to Facility Self-Reported Incident #97868 was substantiated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to follow Care Plan interventions, implement new interventions, and provide supervision at the time of falls for 2 of 3 residents reviewed. | SS=D |
Report Facts
Resident falls: 7
Staffing: 2
Census: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Reported finding Resident #1 on the floor on 6/20/21. |
| Staff B | Certified Nursing Assistant (CNA) | Reported working in Memory Care Unit on 6/20/21 and observed Resident #1 fall. |
| Staff C | Certified Nursing Assistant (CNA) | Assisted another resident while Resident #1 fell on 6/20/21. |
| Staff D | Certified Nursing Assistant (CNA) | Reported Resident #3 fell out of wheelchair on 7/13/21. |
| Staff E | Certified Nursing Assistant (CNA) | Reported being in another room when Resident #3 fell on 7/13/21. |
| Staff F | Registered Nurse (RN) and Scheduling Coordinator | Reported staffing levels and arrival after Resident #3 fall on 7/7/21. |
| Staff G | Registered Nurse (RN) | Worked during falls on 7/7, 7/9, and 7/13/21 and reported staffing shortages. |
| Staff H | Certified Nursing Assistant (CNA) | Reported working first shift on 7/7/21 when Resident #3 fell. |
| Director of Nursing (DON) | Director of Nursing | Reported on staffing, care plan reviews, and fall interventions. |
| MDS Coordinator | MDS Coordinator | Reported reviewing falls daily and updating care plans. |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 1
Jun 2, 2021
Visit Reason
The inspection was conducted as part of the investigation of Complaints #96404 and #97677 and Facility Self-Reported Incidents #97645 and #97659 from May 26 to June 2, 2021.
Findings
The facility failed to ensure adequate supervision and assistance during mechanical lift transfers for one resident, resulting in a fall and injury requiring hospitalization. The resident was transferred alone via Hoyer lift despite care plan requiring two staff, causing a fall with a subdural hematoma and laceration.
Complaint Details
The investigation related to Complaints #96404 and #97677 and Facility Self-Reported Incidents #97645 and #97659 was substantiated.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure adequate supervision and assistance during mechanical lift transfer resulting in resident fall and injury. | SS=G |
Report Facts
Census: 61
Brief Interview for Mental Status (BIMS) score: 10
Subdural hematoma size: 1
Subdural hematoma dimensions: 4.5
Subdural hematoma dimensions: 8
Height of resident during fall: 3.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Named in the finding for performing the unsafe transfer alone |
| Director of Nursing | Director of Nursing (DON) | Reported details of the incident and interviewed Staff A |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 0
Nov 24, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and an investigation of Complaints #92157, #92679, #93116, and #94109 were conducted by the Department of Inspection and Appeals from 10/28/2020 to 11/24/2020.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. All complaints were not substantiated.
Complaint Details
Complaints #92157, #92679, #93116, and #94109 were investigated and found to be not substantiated.
Inspection Report
Routine
Census: 57
Deficiencies: 2
Sep 8, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and an Onsite Revisit were conducted by the Department of Inspections and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be noncompliant with infection prevention and control requirements, including failure to implement an effective visitor screening process and failure to notify residents and their representatives of positive COVID-19 cases in a timely manner.
Deficiencies (2)
| Description |
|---|
| Failed to implement and monitor an effective screening process for visitors to prevent COVID-19 transmission. |
| Failed to notify residents and their representatives/families by 5 p.m. the next calendar day following confirmed COVID-19 infections. |
Report Facts
Resident census: 57
Positive COVID-19 cases: 2
Brief Interview for Mental Status (BIMS) score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Visitor F | Nurse from another facility | Named in relation to screening on a resident |
| Staff A | Hospice Caregiver | Interviewed regarding entry and screening procedures |
| Director of Nursing | Interviewed regarding visitor screening and notification policies | |
| Receptionist | Interviewed regarding visitor screening and sign-in procedures | |
| Social Services Designee | Interviewed regarding notification of residents and families after positive COVID-19 tests |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 4
Aug 10, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and an investigation of Complaints #92333 and #92410 were conducted due to concerns about infection control and quality of care related to COVID-19.
Findings
The facility was found noncompliant with CMS and CDC recommended practices for COVID-19 preparation. Deficiencies included failure to document complete assessments and vital signs for COVID-19 positive residents, inconsistent staff screening and monitoring leading to a COVID-19 outbreak affecting 36 residents with 5 hospitalizations, failure to restrict visitors per CMS guidance, and lack of required staff in-service training and annual evaluations.
Complaint Details
The investigation was triggered by Complaints #92333 and #92410, both substantiated, related to infection control and quality of care during the COVID-19 pandemic.
Severity Breakdown
SS=E: 1
SS=B: 2
SS=L: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to document complete assessments and vital signs for four COVID-19 positive residents. | SS=E |
| Failure to provide documentation of annual evaluations for six staff members. | SS=B |
| Failure to implement and monitor an effective staff screening process to prevent COVID-19 outbreak. | SS=L |
| Failure to provide required 12 hours per year of in-service training for nurse aides. | SS=B |
Report Facts
Residents affected by COVID-19 outbreak: 36
Residents hospitalized due to COVID-19: 5
Staff members without annual evaluations: 6
Certified Nurse Aides without required in-service training: 2
Facility census: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse (RN) | Named in complaint investigation and staff screening process |
| Staff G | Certified Nurse Aide (CNA) | Named in annual evaluation and in-service training deficiencies |
| Staff S | Certified Nurse Aide (CNA) | Named in annual evaluation and in-service training deficiencies |
| Staff P | Licensed Practical Nurse (LPN) | Named in annual evaluation deficiency |
| Staff C | Registered Nurse (RN) | Named in annual evaluation deficiency |
| Staff T | Maintenance | Named in annual evaluation deficiency |
| Staff U | Registered Nurse (RN) | Involved in staff screening observations |
| Staff V | Certified Nurse Aide (CNA) | Observed working while symptomatic and involved in screening process |
| Director of Nursing | Director of Nursing (DON) | Named in multiple interviews regarding infection control and screening |
| Administrator | Administrator | Named in interviews regarding staff evaluations and visitor restrictions |
Inspection Report
Routine
Census: 80
Deficiencies: 0
Jun 22, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 80
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