Inspection Reports for Solon Nursing Care Center

523 East Fifth Street, IA, 523339620

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Deficiencies per Year

12 9 6 3 0
2020
2021
2022
2023
2024
2025
Severe High Moderate Low Unclassified

Census Over Time

40 50 60 70 80 90 Jun '20 Nov '20 Feb '22 Jan '23 Apr '24
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
NameTitleContext
Staff ERegistered NurseNamed in failure to respond to call light and supervision findings
Staff BDirector of NursingReported on Resident #2's call light use and supervision
Staff AAdministratorReported on call light system usage and issues
Staff CCertified Nurse AideObserved resident prior to fall and assisted with care
Staff DCertified Nurse AideObserved resident on floor bleeding after fall
Staff FCertified Nurse AideReceived 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)
DescriptionSeverity
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
NameTitleContext
Staff CLicensed Practical NurseReported call light notification system and response expectations
Staff DRegistered NurseReported call light response expectations and catheter care
Staff FCertified Nurse AideReported call light response expectations and catheter care
Staff GCertified Nurse AideReported call light response expectations and catheter care
Staff ACertified Nurse AideReported call light response expectations and catheter care
Director of NursingDirector of NursingProvided expectations for call light response, catheter care, wander guard monitoring, and oxygen administration
AdministratorAdministratorReported lack of policies on call lights and wander guard monitoring
Staff ERestorative AideReported checking wander guards Monday through Friday
Staff HCertified Nurse AideReported resident wander guard use and monitoring
Social Service StaffReported review and correction of PASRR assessments
Assistant Director of NursingAssistant Director of NursingReported expectations for PASRR accuracy
Maintenance SupervisorReported 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)
DescriptionSeverity
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
NameTitleContext
Staff NRegistered NurseReported issues with colostomy evaluation and pain documentation for Resident #9.
Staff JLicensed Practical NurseReported fall protocol and care plan update issues.
Staff ALicensed Practical NurseReported Resident #4's wound care and heat register injury.
Staff DLicensed Practical NurseReported care plan and wound assessment responsibilities.
Staff GWound Care PhysicianReported pressure ulcer preventability and hospital referral.
Hospice NurseReported pain management and colostomy care issues for Resident #9.
PharmacistReported no communication regarding Stomahesive spray and medication order issues.
Director of NursingDONReported 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)
DescriptionSeverity
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
NameTitleContext
Staff FLicensed Practical Nurse (LPN)Named in failure to administer pain medication to Resident #9 and disciplinary action
Staff KLicensed Practical Nurse (LPN)/acting Director of Nursing (DON)Reviewed Emergency Medication Kit, verified medication delivery, and disciplinary action
Staff GRegistered Nurse (RN)Reviewed medication cart and reported on medication orders and pain management
Staff ALicensed Practical Nurse (LPN)Reported on medication order process and pain management
Staff DCertified Nurse Aide (CNA)Reported resident's pain behaviors
Staff IRegistered Nurse (RN)Reported on pain medication effectiveness and monitoring
Staff LCertified 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)
DescriptionSeverity
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
NameTitleContext
Staff ALicensed Practical NurseNamed in fall and medication administration deficiencies
Staff BCertified Nursing AssistantNamed in visitor restriction and infection control deficiencies
Staff FCertified Nursing AssistantNamed in infection control and COVID vaccination deficiencies
Staff HRegistered NurseNamed in fall and COVID vaccination deficiencies
Staff ICertified Nursing AssistantNamed in elopement incident
Staff JLicensed Practical NurseNamed in COVID testing deficiencies
Staff KCertified Nursing AssistantNamed in fall incident investigation
Staff PLicensed Practical NurseNamed in medication administration and pain management deficiencies
Staff SLicensed Practical NurseNamed in pain management deficiency
Staff UCertified Nursing AssistantNamed in COVID testing and vaccination deficiencies
Staff WDietary AideNamed in COVID testing deficiencies
Staff ZCertified Nursing AssistantNamed in elopement incident
Staff CCEnvironmental AideNamed in abuse training deficiency
Staff KKCertified Nursing AssistantNamed 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)
DescriptionSeverity
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
NameTitleContext
Staff ARegistered Nurse (RN)Reported finding Resident #1 on the floor on 6/20/21.
Staff BCertified Nursing Assistant (CNA)Reported working in Memory Care Unit on 6/20/21 and observed Resident #1 fall.
Staff CCertified Nursing Assistant (CNA)Assisted another resident while Resident #1 fell on 6/20/21.
Staff DCertified Nursing Assistant (CNA)Reported Resident #3 fell out of wheelchair on 7/13/21.
Staff ECertified Nursing Assistant (CNA)Reported being in another room when Resident #3 fell on 7/13/21.
Staff FRegistered Nurse (RN) and Scheduling CoordinatorReported staffing levels and arrival after Resident #3 fall on 7/7/21.
Staff GRegistered Nurse (RN)Worked during falls on 7/7, 7/9, and 7/13/21 and reported staffing shortages.
Staff HCertified Nursing Assistant (CNA)Reported working first shift on 7/7/21 when Resident #3 fell.
Director of Nursing (DON)Director of NursingReported on staffing, care plan reviews, and fall interventions.
MDS CoordinatorMDS CoordinatorReported 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)
DescriptionSeverity
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
NameTitleContext
Staff ACertified Nursing Assistant (CNA)Named in the finding for performing the unsafe transfer alone
Director of NursingDirector 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
NameTitleContext
Visitor FNurse from another facilityNamed in relation to screening on a resident
Staff AHospice CaregiverInterviewed regarding entry and screening procedures
Director of NursingInterviewed regarding visitor screening and notification policies
ReceptionistInterviewed regarding visitor screening and sign-in procedures
Social Services DesigneeInterviewed 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)
DescriptionSeverity
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
NameTitleContext
Staff BRegistered Nurse (RN)Named in complaint investigation and staff screening process
Staff GCertified Nurse Aide (CNA)Named in annual evaluation and in-service training deficiencies
Staff SCertified Nurse Aide (CNA)Named in annual evaluation and in-service training deficiencies
Staff PLicensed Practical Nurse (LPN)Named in annual evaluation deficiency
Staff CRegistered Nurse (RN)Named in annual evaluation deficiency
Staff TMaintenanceNamed in annual evaluation deficiency
Staff URegistered Nurse (RN)Involved in staff screening observations
Staff VCertified Nurse Aide (CNA)Observed working while symptomatic and involved in screening process
Director of NursingDirector of Nursing (DON)Named in multiple interviews regarding infection control and screening
AdministratorAdministratorNamed 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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