Inspection Reports for The Solana Doylestown
1621 Easton Rd, Warrington, PA 18976, United States, PA, 18976
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32
24
16
8
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Census Over Time
Census
Capacity
Inspection Report
Monitoring
Census: 82
Capacity: 129
Deficiencies: 9
Apr 23, 2025
Visit Reason
The inspection was a monitoring visit conducted on April 23, 2025, to review the facility's compliance with regulatory requirements and the implementation of a previously submitted plan of correction.
Findings
Multiple deficiencies were identified including unsafe bedside mobility devices, unsecured poisonous materials accessible to residents, trash improperly stored outside, lack of current rabies vaccination certificates for some cats, emergency procedures not posted conspicuously, and medication storage and documentation issues including loose pills, unlabeled medications, and glucometer reading discrepancies.
Deficiencies (9)
| Description |
|---|
| Upside down large u-shaped bedside mobility devices not attached to beds creating entrapment hazards; one device covered with a loose pillowcase not meeting FDA guidelines. |
| Poisonous deodorant accessible and unlocked in memory care resident's bedroom; residents not assessed capable of safely using poisons. |
| Ground around dumpster covered in loose garbage including disposable cups and containers. |
| Two of four cats present lacked current rabies vaccination certificates; vaccinations expired on 6/13/2024 and 1/27/2025. |
| Emergency procedures not posted in a conspicuous and public place; binder found in drawer behind front desk. |
| Loose pills observed in medication carts on multiple floors including white oblong, round white, and orange pills. |
| Medication cards with punctured foil backing but pills still present for multiple residents. |
| Over-the-counter medications and CAM not labeled with resident names in medication carts. |
| Resident's glucometer not calibrated correctly; discrepancies between glucometer readings and Medication Administration Record (MAR) documentation. |
Report Facts
License Capacity: 129
Residents Served: 82
Memory Care Capacity: 32
Memory Care Residents Served: 30
Current Hospice Residents: 4
Residents with Mobility Need: 37
Residents with Physical Disability: 1
Residents 60 Years or Older: 82
Cats Present: 4
Overdue Rabies Vaccinations: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Plant Operations Director | Removed bedside devices and responsible for monthly audits of devices and security straps. | |
| Director of Nursing | Sent safer device suggestions to families and involved in installation and evaluation of bedside devices. | |
| Memory Care Director | Spoke with resident's family about poisonous materials and responsible for daily spot checks of poisonous materials storage. | |
| Director of Health Care Services | Conducted training on sanitation, responsible for auditing medication storage and medication staff meetings. | |
| Business Office Manager | Received overdue vaccination records, manages vaccination reminders, and responsible for emergency procedures binder accessibility. | |
| Executive Director | Posted emergency procedures binder and responsible for ensuring its accessibility. | |
| Medication Technicians | Assigned to audit medications weekly including inspections for punctures, expired medications, loose pills, and labeling. | |
| Health Services Assistant | Conducts biweekly audits of medications. |
Inspection Report
Renewal
Census: 79
Capacity: 129
Deficiencies: 21
Feb 11, 2025
Visit Reason
The inspection was conducted as a renewal and complaint investigation visit to assess compliance with licensing requirements and address complaints.
Findings
The inspection identified multiple deficiencies including expired boiler and elevator certificates, privacy violations, unsafe storage of poisonous materials, uncovered trash receptacles, unlabeled and undated food items, medication storage and labeling issues, incomplete emergency preparedness documentation, and resident record access issues. Plans of correction were accepted with proposed completion dates mostly in March 2025, with some corrections implemented by May 2025.
Complaint Details
The inspection included a complaint investigation component related to privacy violations, medication administration, emergency preparedness, and resident record access. Some complaints were substantiated as deficiencies.
Deficiencies (21)
| Description |
|---|
| Boiler certificates for the home's three boilers have been expired since 8/31/2020. |
| Amazon Alexa in the Memory care unit common area with no signs posted about audio recording. |
| Resident 1's bedside mobility device had an uncovered opening measuring 11 inches x 7 inches. |
| Poisonous materials (Clorox wipes, acetone nail polish remover, Dermasil body wash) were unlocked and accessible in resident 2's room. |
| Full, uncovered, unattended trash can in the Memory Care kitchenette. |
| Two mattresses and a broken enabler bar were left outside the dumpster area. |
| Two elevators lacked valid certificates of operation; last expired on 9/30/2024. |
| Unlabeled, undated leftovers found in the memory care kitchenette refrigerator. |
| Undated ice cream in main kitchen freezer and unlabeled, undated white substance in memory care kitchenette refrigerator. |
| Approximate 1/2 inch accumulation of lint in the lint trap of the Memory care dryer. |
| Staff person 3 did not have the emergency preparedness plan for the local municipality. |
| Written emergency procedures had not been sent to the local emergency management office. |
| Two cats present without current certificates of rabies vaccination. |
| Weekly menu posted did not include breakfast. |
| Resident 4 self-administers medications without assessment by a qualified medical professional. |
| MiraLAX and Ibuprofen were unlocked and accessible on resident 4's counter; resident 4 does not lock their room door. |
| Resident 5's Gabapentin and resident 6's Trazodone pills had punctures; loose pills found in medication carts. |
| OTC Aspirin in memory care medication cart was not labeled with a resident's name. |
| Resident 7's glucometer readings were inaccurately documented on medication administration records. |
| Preadmission screening forms for residents 8, 9, and 10 were completed after admission. |
| Staff person 3 refused to provide resident 11's designated person with access to reportable incidents from the resident's record. |
Report Facts
License Capacity: 129
Residents Served: 79
Secured Dementia Care Unit Capacity: 32
Residents Served in Dementia Care Unit: 28
Hospice Residents: 3
Total Daily Staff: 115
Waking Staff: 86
Residents 60 Years or Older: 78
Residents with Mobility Need: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Registered with PA Department of Labor Industry to manage boiler and elevator certificates; involved in corrective actions. | |
| Memory Care Director | Removed Amazon Alexa, conducted in-services on food storage and trash receptacles, performed spot checks, and involved in multiple corrective actions. | |
| Director of Health Care Services | Conducted in-services and audits related to medication administration, storage, and self-administration assessments. | |
| Business Office Manager | Contacted families for updated pet vaccinations and will conduct quarterly audits. | |
| Director of Nursing | Responsible for monthly audits of medication carts. | |
| Lead Housekeeper | Assigned to check lint traps in dryers. | |
| Staff Person 3 | Did not have emergency preparedness plan and refused to provide resident records. |
Inspection Report
Follow-Up
Census: 82
Capacity: 129
Deficiencies: 2
Jan 7, 2025
Visit Reason
The inspection visit was conducted as a follow-up to review the submitted plan of correction related to a complaint and incident at the facility.
Findings
The submitted plan of correction was determined to be fully implemented as of the inspection date. The report includes details of deficiencies related to failure to report a resident incident and incomplete contract signatures, with corrective actions completed and ongoing monitoring planned.
Complaint Details
The visit was complaint-related and incident-driven. The complaint involved failure to report a resident's hospital admission and death, and issues with contract signatures. The plan of correction was accepted and fully implemented.
Deficiencies (2)
| Description |
|---|
| Failure to report a resident incident to the department within 24 hours as required. |
| Resident-home contract was not signed by the resident's designated person, and the contract did not document that the resident was given the opportunity to sign. |
Report Facts
License Capacity: 129
Residents Served: 82
Memory Care Capacity: 34
Memory Care Residents Served: 29
Residents Age 60 or Older: 81
Residents with Mobility Need: 66
Residents with Physical Disability: 1
Total Daily Staff: 148
Waking Staff: 111
Inspection Report
Complaint Investigation
Census: 77
Capacity: 129
Deficiencies: 3
Jan 18, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection on 01/18/2024 and an off-site review on 01/23/2024.
Findings
The facility was found to have deficiencies related to fire safety orientation for new staff, medication labeling, and following prescriber's orders. The submitted plan of correction was fully implemented by 04/04/2024.
Complaint Details
The inspection was complaint-related with a reason stated as Complaint, Incident. The plan of correction was accepted and fully implemented.
Deficiencies (3)
| Description |
|---|
| Staff person did not receive orientation on evacuation procedures, staff duties during fire drills and emergencies, designated meeting place, smoking safety, fire extinguisher use, smoke detectors, and emergency telephone use. |
| Resident's medication container lacked a pharmacy label including resident's name, medication name, prescription date, dosage instructions, and prescriber information. |
| The home did not follow prescriber's orders for medication administration times and proper documentation for residents on leave of absence (LOA). |
Report Facts
License Capacity: 129
Residents Served: 77
Secured Dementia Care Unit Capacity: 34
Residents Served in SDCU: 19
Current Hospice Residents: 2
Residents with Mobility Need: 32
Residents 60 Years or Older: 77
Residents Diagnosed with Mental Illness: 1
Residents with Physical Disability: 1
Inspection Report
Census: 77
Capacity: 129
Deficiencies: 0
Dec 18, 2023
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
License Capacity: 129
Residents Served: 77
Memory Care Unit Capacity: 30
Memory Care Unit Residents Served: 19
Current Hospice Residents: 1
Residents Age 60 or Older: 77
Residents with Mobility Need: 44
Residents with Physical Disability: 2
Inspection Report
Monitoring
Census: 69
Capacity: 129
Deficiencies: 7
May 31, 2023
Visit Reason
The inspection was an unannounced partial monitoring visit conducted to review the facility's compliance with licensing requirements and the implementation of a previously submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including missing emergency telephone numbers in resident rooms, overdue annual medical evaluations, expired medications, discrepancies in medication administration records, incomplete preadmission screenings, and delayed admission support plans. All deficiencies had plans of correction accepted and were reported as implemented by the follow-up date.
Deficiencies (7)
| Description |
|---|
| No emergency telephone numbers including nearest hospital and fire department posted on or by the telephone in resident rooms #222 and #302. |
| Resident #1 had not had an annual medical evaluation since initial evaluation in 2021. |
| Expired medication (Tramadol 50 mg) found in the home's 2nd floor medication cart. |
| Discrepancies between resident #3's glucometer readings and log entries. |
| Medication administration records for multiple residents lacked staff initials at time of administration. |
| Resident #6's cognitive preadmission screening was completed after admission to the secured dementia care unit. |
| Resident #6's initial admission support plan was not completed within 72 hours of admission to the secured dementia care unit. |
Report Facts
License Capacity: 129
Residents Served: 69
Memory Care Capacity: 34
Residents Served in Memory Care: 17
Staffing Hours - Total Daily Staff: 90
Staffing Hours - Waking Staff: 68
Medication Count: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Plant Operations Director | Replaced phone and added emergency number tags in resident rooms #222 and #302. | |
| Director of Health Care Services | Managed correction of overdue medical evaluations, removal of expired medication, staff training, and completion of resident #6's support plan. | |
| Director of Nursing | Reviewed all other annual medical evaluations and responsible for monthly audits. | |
| Medication Technician | Received training on correct reporting and medication administration. | |
| LPN | Provided in-service training on 5 Rights of Medication Administration and placed agency staff on 'do not return' list. | |
| State Surveyor | Reviewed regulations with Director of Health Care Services regarding preadmission screening. |
Inspection Report
Renewal
Census: 69
Capacity: 129
Deficiencies: 30
Mar 27, 2023
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 03/27/2023 and 03/28/2023 to review compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies across various areas including posting of licenses and influenza information, resident funds refund delays, staff qualifications, safety issues such as unlocked poisonous materials and uncovered trash receptacles, water temperature problems, emergency telephone postings, furniture hazards, incomplete first aid kits, food storage violations, emergency procedure submissions, obstructed egress, incomplete medical evaluations and assessments, medication administration errors, and incomplete resident records. Plans of correction were accepted and many deficiencies were noted as repeated violations.
Deficiencies (30)
| Description |
|---|
| A copy of the chapter was not posted in a conspicuous and public place in the home. |
| No Influenza poster posted in an area accessible to residents. |
| Resident owed $5504.20 refund not issued within 30 days of discharge. |
| Direct care staff person does not have required high school diploma, GED, or active registry status. |
| Kitchen in Secured Dementia Care Unit unlocked with poisonous materials accessible to residents not assessed capable of safe use. |
| Trash cans in kitchen had no lids. |
| Bathroom in resident room #107 did not have hot water. |
| Hot water temperature in bathrooms exceeded 120°F in resident rooms #327 and #129. |
| Emergency telephone numbers missing on or by telephones in resident rooms #302 and #216. |
| Resident room #222 had a bed equipped with an uncovered enabler. |
| First aid kit in nurse's station missing adhesive bandages, adhesive tape, scissors, and eye coverings. |
| Three of five ice cream containers in freezer were opened and unsealed. |
| Written emergency procedures not submitted to local emergency management agency since 2020. |
| Exit door from dining room was unhinged at the top, making doorway impassable. |
| Resident medical evaluations incomplete or missing required information including ability to self-administer medications and cognitive functioning. |
| Resident medical evaluations not completed annually as required. |
| Resident self-administers medications stored in unlocked drawer and does not lock door when leaving. |
| Medication administration errors including incorrect signing out of controlled substances and conflicting medication orders. |
| Expired or discontinued medications found in medication cart. |
| Prescription medications not stored with proper labeling or discard dates. |
| Medication record did not indicate units given for insulin aspart flexpen as ordered. |
| Medication administration records missing staff initials or showing discrepancies in medication given. |
| Medications not given as prescribed or medication labels not matching orders. |
| Resident preadmission screening form missing determination that resident needs can be met by services provided. |
| Resident assessments not completed annually as required. |
| Resident medical evaluation not completed for transfer to secured dementia care unit. |
| Resident not assessed annually for continuing need for secured dementia care unit. |
| Resident support plan not completed within 72 hours of admission to secured dementia care unit. |
| Resident support plan not revised annually as required. |
| Resident records missing preadmission screening forms. |
Report Facts
License Capacity: 129
Residents Served: 69
Secured Dementia Care Unit Capacity: 34
Residents Served in Secured Dementia Care Unit: 16
Current Hospice Residents: 3
Residents with Mobility Need: 18
Residents with Physical Disability: 1
Resident Refund Amount: 5504.2
Staff Total Daily: 87
Staff Waking: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Direct Care Staff Person | Named in deficiency for lacking required qualifications. |
| Plant Director | Named in deficiencies related to locking poisonous materials, emergency telephone postings, water temperature audits, and egress repairs. | |
| Business Office Manager | Named in deficiencies related to resident funds refund and staff file audits. | |
| Executive Director | Named in deficiencies related to posting requirements, influenza information, resident funds refund, and emergency procedure submissions. | |
| Culinary Director | Named in deficiencies related to trash receptacles, food storage, and menu postings. | |
| DOHS | Multiple references as responsible for audits, education, and corrective actions related to medication administration, resident evaluations, and compliance monitoring. |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 129
Deficiencies: 8
Sep 26, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation with unannounced partial inspections on 09/26/2022, 09/27/2022, and 10/05/2022 to review compliance with regulations.
Findings
Multiple deficiencies were found related to resident contracts not being signed, missing signed statements acknowledging receipt of resident rights, incomplete medical evaluations, missing preadmission screening forms, unsigned support plans, and inadequate documentation for secured dementia care unit admissions. Plans of correction were accepted and implemented by 11/07/2022.
Complaint Details
The inspection was complaint-related, triggered by complaints and incidents as noted in the inspection information section. The plan of correction was accepted and fully implemented.
Deficiencies (8)
| Description |
|---|
| Resident-home contracts for residents #1 and #2 were not signed by the residents. |
| Resident #1 and #2's records did not contain signed statements acknowledging receipt of resident rights and complaint procedures. |
| Resident #1's medical evaluation lacked a general physical examination and medication regimen; Resident #2's medical evaluation lacked special health or dietary needs, medication regimen, body positioning, movement stimulation, and cognitive functioning. |
| Resident #1's initial medical evaluation was not completed timely; a new medical evaluation was not completed when the resident entered a new care level. |
| Residents #1, #2, #3, and #4 participated in support plan development but did not sign their support plans. |
| Preadmission screening forms were not completed for residents #1 and #4 prior to admission. |
| Resident #3 and #4's medical evaluations did not indicate the need for secured dementia care unit placement. |
| Resident #4's written cognitive preadmission screening was not completed within 72 hours prior to admission to the secured dementia care unit. |
Report Facts
License Capacity: 129
Residents Served: 71
Secured Dementia Care Unit Capacity: 34
Secured Dementia Care Unit Residents Served: 19
Residents Diagnosed with Mental Illness: 27
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 32
Residents with Physical Disability: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named in relation to oversight of contract signatures, preadmission screening, and auditing compliance | |
| Business Office Manager | Named in relation to auditing resident contracts and preadmission screening compliance | |
| Sales & Marketing Director | Named in relation to ensuring resident contracts and rights forms are signed | |
| Director of Health Care Services | Named in relation to ensuring medical evaluations are complete and auditing compliance | |
| LPN staff | Licensed Practical Nurse | Named in relation to auditing medical evaluations and support plans |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 129
Deficiencies: 7
Mar 11, 2022
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations at THE SOLANA DOYLESTOWN facility.
Findings
The inspection identified multiple deficiencies including privacy violations during medication administration, incomplete or untimely annual medical evaluations, medication administration record inaccuracies, failure to follow prescriber's orders, and incomplete resident assessments and support plans.
Complaint Details
The inspection was complaint-driven, with a follow-up plan of correction submission required by 03/31/2022.
Deficiencies (7)
| Description |
|---|
| Residents in the memory care unit are administered medications in the dining room while other residents are present, violating privacy rights. |
| Resident #1 and #2 had incomplete or missing annual medical evaluations. |
| Medication Administration Records for residents #1, #3, and #4 lacked specific medication administration times. |
| Medication administration records were not updated at the time medications were given for residents #1, #3, and #4. |
| Resident #1, #3, and #4 were not administered prescribed medications on multiple dates as ordered by prescribers. |
| Resident #3's initial assessment and support plan were not completed within required timeframes. |
| Resident #2 and #4 had incomplete additional assessments and missing signatures on support plans. |
Report Facts
License Capacity: 129
Residents Served: 78
Memory Care Capacity: 30
Memory Care Residents Served: 28
Hospice Residents: 2
Total Daily Staff: 110
Waking Staff: 83
Residents with Mobility Need: 32
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 71
Capacity: 129
Deficiencies: 7
Sep 14, 2021
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements for THE SOLANA DOYLESTOWN facility.
Findings
The inspection identified multiple deficiencies related to staff qualifications, orientation and training, safety measures including locking poisonous materials, lighting in resident rooms, and medication storage. Plans of correction were accepted and documented as implemented.
Deficiencies (7)
| Description |
|---|
| Direct Care Staff Person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Staff Person B did not receive orientation on the first day of work. |
| Staff Person B did not complete required 40-hour rights/abuse training within scheduled hours. |
| Direct Care Staff Person A began providing unsupervised ADL services without completing and passing the Department-approved direct care training course and competency test. |
| Crest Toothpaste with a warning label was unlocked, unattended, and accessible to residents, including those in the secured dementia care unit who have not been assessed capable of recognizing and using poisons safely. |
| Resident Bedroom 115B does not have access to a source of light that can be turned on/off at bedside. |
| Several unlocked, unattended medications were found in Resident #1's bedroom despite self-administration requirements for locked storage. |
Report Facts
License Capacity: 129
Residents Served: 71
Secured Dementia Care Unit Capacity: 30
Residents Served in Secured Dementia Care Unit: 28
Current Hospice Residents: 4
Total Daily Staff: 104
Waking Staff: 78
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