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 are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a April 2024 inspection.
Census over time
Inspection Report
Annual InspectionInspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Annual InspectionInspection Report
Re-InspectionInspection Report
Complaint Investigation| 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 InvestigationInspection Report
Plan of CorrectionInspection Report
Annual Inspection| 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-InspectionInspection Report
Complaint Investigation| 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 InvestigationInspection Report
Re-InspectionInspection Report
Complaint Investigation| 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
| 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 SurveyInspection Report
Complaint InvestigationInspection Report
Complaint Investigation| 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| 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 InvestigationInspection Report
Routine| 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| 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
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