Cycle 1
Health 2025-12-18 · Fire 2025-12-18
15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Los Angeles, CA
Solheim Senior Community
3-star overall rating with 3-star inspections with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
2236 Merton Ave., Los Angeles, CA
(323) 257-7518
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
76
Certified beds
Average residents
64
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-05-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.45
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.34
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.73
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.53
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.80
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.12
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
4.36
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,530
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.38
Composite VBP score used to determine payment impact.
Payment multiplier
0.9831
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.23% · Performance 21.49% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.87% · Performance 8.14% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.14
Performance 42.67% · Measure score 5.14 · Achievement 5.14 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.21
Baseline 4.18 hours · Performance 4.28 hours · Measure score 4.21 · Achievement 4.21 · Improvement 0.12
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.79% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 97 · Observed rate 5.15% · Lower 95% interval 6.54% |
| Discharge to community | 54.14% |
50.57%
3.6 pts better
|
No Different than the National Rate · Eligible stays 82 · Observed rate 52.44% · Lower 95% interval 45.25% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 63 · Denominator 63 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 63 |
| Discharge self-care score | 57.5% |
53.69%
3.8 pts better
|
Numerator 23 · Denominator 40 |
| Discharge mobility score | 62.5% |
50.94%
11.6 pts better
|
Numerator 25 · Denominator 40 |
| Pressure ulcers or injuries, new or worsened | 4.76% |
2.29%
2.5 pts worse
|
Numerator 3 · Denominator 63 · Adjusted rate 3.17% |
| Healthcare-associated infections requiring hospitalization | 8.14% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 61 · Observed rate 9.84% · Lower 95% interval 4.58% |
| Staff COVID-19 vaccination coverage | 22.22% |
8.2%
14 pts better
|
Numerator 22 · Denominator 99 |
| Staff flu vaccination coverage | 47.67% |
42%
5.7 pts better
|
Numerator 41 · Denominator 86 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 20 · Denominator 40 |
| Transfer of health information to provider | 95.65% |
95.95%
0.3 pts worse
|
Numerator 22 · Denominator 23 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 27 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 25.93% |
25.2%
0.7 pts better
|
Numerator 7 · Denominator 27 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
2.3
0.3 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 1.7 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.6
1 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.4 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.0% |
98.2%
1.2 pts worse
|
95.5%
1.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.3% |
1.6%
3.7 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 4.8% · Q3 6.5% · Q4 8.8% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 9.0% |
4.1%
4.9 pts worse
|
5.4%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 5.4% · Q3 7.1% · Q4 15.1% · 4Q avg 9.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.2% |
13.7%
2.5 pts better
|
19.6%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 10.7% · Q3 13.8% · Q4 7.5% · 4Q avg 11.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.1% |
14.2%
0.1 pts better
|
16.7%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 14.9% · Q3 14.6% · Q4 16.3% · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.7% |
11.0%
11.7 pts worse
|
16.3%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.6% |
10.7%
1.9 pts worse
|
14.9%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 23.3% · Q3 4.9% · Q4 17.5% · 4Q avg 12.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.0%
0.2 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 1.9% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.2%
About the same
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 1.7% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.5% |
10.9%
2.6 pts worse
|
19.8%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 12.9% · Q3 9.1% · Q4 23.6% · 4Q avg 13.5% |
| Percentage of long-stay residents with pressure ulcers | 7.9% |
4.7%
3.2 pts worse
|
5.1%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 9.3% · Q3 10.1% · Q4 5.3% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
94.0%
4.2 pts better
|
81.7%
16.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.1% · Q2 97.4% · Q3 100.0% · Q4 100.0% · 4Q avg 98.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
11.2%
2.1 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 8.3% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.7% |
1.5%
3.2 pts worse
|
1.6%
3.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 6.5% · Q4 9.1% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.2%
6.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.8% |
23.2%
7.6 pts worse
|
23.9%
6.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.8% · Observed 27.1% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-11 · Fire 2024-10-11
9 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2023-10-05 · Fire 2023-10-05
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-12-18
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2026-01-15
D · Potential for more than minimal harm
2025-12-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-01-15
F · Potential for more than minimal harm
2024-10-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-03
F · Potential for more than minimal harm
2024-10-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-03
E · Potential for more than minimal harm
2024-10-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-03
D · Potential for more than minimal harm
2024-10-11
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-11-03
D · Potential for more than minimal harm
2024-10-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-03
D · Potential for more than minimal harm
2024-10-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-11-03
E · Potential for more than minimal harm
2023-10-05
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-10-05
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-10-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-18
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2026-01-15
E · Potential for more than minimal harm
2025-12-18
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-01-15
E · Potential for more than minimal harm
2025-12-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-01-15
E · Potential for more than minimal harm
2025-12-18
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2026-01-15
E · Potential for more than minimal harm
2025-12-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-01-15
E · Potential for more than minimal harm
2025-12-18
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2026-01-15
E · Potential for more than minimal harm
2025-12-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-15
E · Potential for more than minimal harm
2025-12-18
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2026-01-15
E · Potential for more than minimal harm
2025-12-18
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2026-01-15
D · Potential for more than minimal harm
2025-12-18
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2026-01-15
D · Potential for more than minimal harm
2025-12-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-15
D · Potential for more than minimal harm
2025-12-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-15
D · Potential for more than minimal harm
2025-12-18
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2026-01-15
G · Actual harm
2025-11-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-11-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-12-10
E · Potential for more than minimal harm
2024-10-11
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-10-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-10-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-10-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-11
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-11
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-11-07
E · Potential for more than minimal harm
2023-10-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-31
E · Potential for more than minimal harm
2023-10-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-10-31
E · Potential for more than minimal harm
2023-10-05
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-10-31
E · Potential for more than minimal harm
2023-10-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-10-05
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-10-05
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-10-05
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-10-05
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-10-05
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-10-05
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-10-05
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-10-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-10-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-06-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-22
Penalties and ownership
What sits behind the stars
Ownership
Auer, Susan
Operational/Managerial Control · Individual
Bos, Brenda
Operational/Managerial Control · Individual
Bos, Brenda
Corporate Director · Individual
Cox, Thomas
Operational/Managerial Control · Individual
Egge, Paul
Operational/Managerial Control · Individual
Egge, Paul
Corporate Director · Individual
Garcia, Frederick
Operational/Managerial Control · Individual
Gerringer, Robert
Corporate Director · Individual
Johnson, Joseph
Operational/Managerial Control · Individual
Kallman, Kenneth
Corporate Director · Individual
Keedy, Cl
Corporate Director · Individual
Killian, Charles
Operational/Managerial Control · Individual
Magardornyan, Ekik
Operational/Managerial Control · Individual
Mohr, Garry
Operational/Managerial Control · Individual
Navarro, Adria
Operational/Managerial Control · Individual
Navarro, Adria
Corporate Director · Individual
Oden, Samuel
Corporate Officer · Individual
Pierce, Meg
Operational/Managerial Control · Individual
Solheim Lutheran Home
Operational/Managerial Control · Organization
Stark, Susan
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Ararat Convalescent Hospital
Los Angeles, CA
4-star overall rating with 3-star inspections with $10,039 in total fines with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
College Vista Post-Acute
Los Angeles, CA
2-star overall rating with 2-star inspections with $43,568 in total fines with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Glendale Adventist Medical Center Dp/Snf
Glendale, CA
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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