Inspection Reports for
Columbia Cottage-Collegeville, LLC
901 E. MAIN STREET, COLLEGEVILLE, PA, 19426
Back to Facility Profile19 Reports
Inspection Report — May 11, 2026
Follow-Up
Date: May 11, 2026
Visit Reason
The inspection was a renewal and incident review conducted as a full, unannounced inspection to verify the implementation of a previously submitted plan of correction.
Findings
The plan of correction was found to be fully implemented with continued compliance required. Two deficiencies were identified and corrected related to sanitary conditions of the kitchen ice maker and the absence of an operable lamp at a resident's bedside.
Citations (2)
85a Sanitary conditions: On 5/11/26, there was a gray colored build up on the main kitchen ice maker. The issue was cleaned and corrected on the same day.
101j7 Lighting/operable lamp: Resident #1 did not have access to a source of light that can be turned on/off at bedside. An operable lamp was immediately placed at the bedside on 5/11/26.
Report Facts
Residents Served: 28
Current Hospice Residents: 7
Inspection Report — Mar 31, 2025
Plan of Correction
Date: Mar 31, 2025
Visit Reason
The inspection was a partial, unannounced incident investigation conducted on 03/31/2025 and 04/01/2025 to review allegations of resident abuse and compliance with abuse reporting and supervision requirements.
Complaint Details
The visit was complaint-related due to an incident where a staff member allegedly shoved a soapy rag into a resident's mouth in retaliation for knocking off the staff member's glasses. The complaint was substantiated with findings of abuse and neglect.
Findings
The facility was found to have multiple violations related to resident abuse, failure to immediately report suspected abuse, failure to suspend staff involved in abuse allegations promptly, inadequate staff training including annual and dementia-specific training, failure to implement positive interventions for combative residents, and use of prohibited manual restraints. The facility submitted and implemented a plan of correction addressing these issues with staff re-education, training, supervision plans, and ongoing compliance monitoring.
Citations (10)
Failure to immediately report suspected abuse of a resident as required by law.
Failure to immediately suspend staff involved in alleged resident abuse and implement a supervision plan.
Failure to report an incident to the Department within 24 hours as required.
Resident abuse and neglect including staff shoving a soapy rag into a resident's mouth and improper handling of a combative resident.
Direct care staff did not receive the required 16 hours of annual training relating to job duties.
Direct care staff did not receive required training in medication self-administration, meeting resident needs, and assisted living service needs.
Direct care staff did not receive training in fire safety by a certified fire safety expert or trained staff.
Direct care staff did not receive required dementia-specific training hours.
Failure to implement positive interventions to modify or eliminate combative behavior during care.
Use of prohibited manual restraint by restricting resident's arm movement with shirt cuffs.
Report Facts
Residents Served: 23
Current Residents in Hospice: 3
Total Daily Staff: 43
Waking Staff: 32
Direct Care Staff Annual Training Hours: 12
Dementia-Specific Training Hours: 1
Inspection Report — Mar 25, 2025
Monitoring
Date: Mar 25, 2025
Visit Reason
The inspection was an unannounced partial monitoring visit conducted on 03/25/2025 to review compliance with licensing requirements and verify the implementation of a previously submitted plan of correction.
Findings
The inspection identified multiple deficiencies related to fire safety (obstructed egress, combustible storage, unsafe smoking area), medication management (discontinued medications, improper storage, labeling errors, incomplete medication records), and storage procedures. All deficiencies were addressed with immediate corrective actions and plans for ongoing monitoring and staff reeducation.
Citations (9)
A large carpet cleaner was blocking the emergency exit egress route near a residence door.
Combustible materials including a straw broom, cardboard boxes, and plastic bins were stored near a heater in a maintenance closet.
The designated outdoor smoking area was not a safe distance from heat sources and combustible materials; red gas cans were found in the smoking area.
A discontinued medication was found in the residence's medication cart.
Medications in the medication cart were not stored according to manufacturer instructions; blister packs were torn and taped.
A prescription medication's pharmacy label lacked a change of direction sticker indicating updated instructions.
A prescribed medication was not available in the residence at the time of inspection.
The medication administration record for a resident did not include the instruction to remove a Lidocaine patch every 12 hours.
The medication administration record did not include the initials of the staff person who administered a medication at a specified time.
Report Facts
Residents Served: 23
Current Residents in Hospice: 3
Resident Support Staff Daily Hours: 44
Waking Staff Daily Hours: 33
Residents Diagnosed with Mental Illness: 15
Residents with Mobility Need: 21
Residents 60 Years or Older: 23
Residents with Physical Disability: 1
Inspection Report — Jan 16, 2025
Follow-Up
Date: Jan 16, 2025
Visit Reason
The inspection was an unannounced partial incident investigation conducted on 01/16/2025 to review compliance following a prior plan of correction submission.
Findings
The facility was found to have deficiencies related to staff training on assisted living service needs, medication storage procedures, and documentation of medication administration times. The submitted plan of correction was determined to be fully implemented as of the follow-up review.
Citations (4)
Direct care staff persons A and B did not receive training in assisted living service needs of the resident during the training year 2024.
Medication administration records did not consistently document narcotic administration times, with discrepancies between MAR and narcotic administration records.
Procedures for safe storage, access, security, distribution, and use of medications were not fully implemented, including lack of narcotic counts and documentation.
Medication administration times were not recorded at the time of administration as required, with multiple instances of missing or inconsistent documentation.
Report Facts
Residents Served: 28
Total Daily Staff: 52
Waking Staff: 39
Current Hospice Residents: 5
Residents Diagnosed with Mental Illness: 16
Residents with Mobility Need: 24
Residents with Physical Disability: 24
Residents Age 60 or Older: 28
Notice — Dec 16, 2024
Date: Dec 16, 2024
Visit Reason
This document serves as a waiver approval for Columbia Cottage – Collegeville, LLC, allowing an individual to serve as administrator while enrolled in the required Assisted Living Administrator orientation course.
Findings
The waiver permits the named individual to serve as administrator under supervision until compliance with training requirements is met by January 30, 2025.
Report Facts
Training course date: Jan 30, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Jul 18, 2024
Renewal
Date: Jul 18, 2024
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 07/18/2024 to review compliance with licensing requirements and verify the implementation of the submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including failure to post the current license conspicuously, missing smoking signage, inadequate carbon monoxide detector placement, abuse/neglect incidents involving staff, and incomplete staff training in fire safety, abuse/neglect, resident rights, and other required topics. Plans of correction were accepted and implemented with ongoing monitoring.
Citations (10)
Failure to post the current license conspicuously; the license posted was expired.
No smoking signs were not posted at the front entrance as required by the Clean Indoor Air Act.
Carbon monoxide detector was not installed within close proximity to the natural gas water heater as required.
Resident #1 was subjected to physical abuse and neglect by Staff Member B, including inappropriate handling and verbal abuse.
Staff Person B lacked required fire safety and emergency preparedness training prior to or during first work day.
Staff Person B lacked required orientation training within 40 scheduled working hours including resident rights and mandatory abuse reporting.
Direct care staff person C did not receive required medication self-administration training and instruction on meeting resident needs during 2023 training year.
Staff Members C and D did not receive training in the Older Adult Protective Services Act during 2023 training year.
Staff Member E did not receive training in the Older Adult Protective Services Act or fire safety training during 2023 training year.
Resident #1's assessment did not reflect a significant change requiring two-person assist; additional written assessment was not completed timely.
Report Facts
Residents Served: 29
Hospice Residents: 7
Residents Age 60 or Older: 29
Residents with Mobility Need: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member B | Agency Staff | Named in abuse/neglect finding and lack of required trainings; terminated due to violations. |
| Staff Person C | Direct Care Staff | Did not receive required medication self-administration training and OAPS training in 2023. |
| Staff Member D | Staff Member | Did not receive required OAPS training in 2023. |
| Staff Member E | Staff Member | Did not receive required OAPS or fire safety training in 2023; fire safety training completed on 08/14/2024. |
Inspection Report — Jul 26, 2023
Renewal
Date: Jul 26, 2023
Visit Reason
The inspection was conducted as a renewal licensing inspection of the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 24
Current Hospice Residents: 4
Resident Support Staff Hours: 0
Total Daily Staff Hours: 40
Waking Staff Hours: 30
Inspection Report — Jul 6, 2022
Renewal
Date: Jul 6, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The inspection identified multiple deficiencies including medication administration errors, outdated food storage, incomplete resident contracts, missing signatures on support plans, and failure to conduct timely fire drills. The facility submitted plans of correction which were accepted and implemented.
Citations (9)
Medication not administered as prescribed to Resident #4 on multiple occasions and medication error not reported to the Department.
Resident #1 did not have a signed resident-residence contract within 24 hours of admission.
Outdated or unlabeled and undated food items found in kitchen and dry storage areas.
Fire drill during sleeping hours not conducted within the required 6-month period.
Medical evaluation for Resident #1 missing diagnoses and TB test information.
Narcotic medication storage and documentation deficiencies including incomplete narcotic counts and improper receipt procedures.
Prescribed medication (Pro Air HFA Aerosol Solution) for Resident #3 was not available in the residence.
Resident #4's medication administration records were inaccurately documented as given when medication was not administered.
Resident #1 participated in support plan development but did not sign and date the support plan.
Report Facts
Residents Served: 28
Total Daily Staff: 44
Waking Staff: 33
Hospice Residents: 4
Residents with Mobility Need: 16
Inspection Report — Apr 5, 2021
Renewal
Date: Apr 5, 2021
Visit Reason
The inspection was conducted as a renewal visit to review the facility's compliance with licensing requirements.
Findings
The facility was found to have a medication documentation discrepancy involving a glucometer reading. The submitted plan of correction was accepted and fully implemented, with ongoing monitoring established.
Citations (1)
On 3/31/21, resident #1's glucometer reading was 173, but 174 was documented on the medication administration record.
Report Facts
Residents Served: 32
Current Hospice Residents: 4
Resident Mobility Need: 15
Notice — Mar 22, 2021
Date: Mar 22, 2021
Visit Reason
The document serves as a renewal notification and license issuance for Columbia Cottage – Collegeville, LLC, an assisted living home, following receipt of the renewal application dated January 27, 2021.
Findings
The Department issued a regular license in response to the renewal application and advised that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
Notice — Jan 31, 2020
Date: Jan 31, 2020
Visit Reason
This document serves as a renewal approval for the assisted living facility Columbia Cottage - Collegeville, LLC, confirming the issuance of a regular license and informing about the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms the license renewal and states that future inspections will be conducted as required by regulation.
Report Facts
Inspection Report — Nov 20, 2019
Renewal
Date: Nov 20, 2019
Visit Reason
The inspection was conducted as a renewal visit to review the facility's compliance and licensing status.
Findings
The facility had violations related to fire extinguisher inspections, menu change notifications, and medication administration. Plans of correction were submitted and fully implemented as of December 27, 2019.
Citations (3)
131f Fire extinguisher inspection: The fire extinguishers in the home have not been inspected by a fire safety expert since 9/2018.
162e Menu changes: On 11/20/19, salmon was listed on the menu but open-faced turkey sandwiches were served instead without prior notice to residents.
187d Follow prescriber's orders: Resident #1 was prescribed Quetiapine twice daily but medication was not administered at the prescribed time on 11/20/19.
Report Facts
Residents Served: 44
Current Hospice Residents: 1
Total Daily Staff: 64
Waking Staff: 48
Residents with Mobility Need: 20
Residents Age 60 or Older: 44
Notice — Feb 28, 2019
Date: Feb 28, 2019
Visit Reason
The document serves as a renewal notice confirming the approval of the renewal application for Columbia Cottage - Collegeville, LLC to operate as an Assisted Living Home.
Findings
No inspection findings are reported in this document. It confirms that a regular license is being issued following the renewal application.
Inspection Report — Nov 15, 2018
Annual Inspection
Date: Nov 15, 2018
Visit Reason
Annual inspection conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 pa. Code Ch. 2800 relating to Assisted Living Residence.
Findings
The facility was found to be in compliance with the applicable regulations during the annual inspection.
Notice — Jan 31, 2018
Date: Jan 31, 2018
Visit Reason
The document serves as a license renewal notification and approval for Columbia Cottage - Collegeville, LLC to operate an assisted living facility with a maximum capacity of 50 residents.
Findings
No inspection findings are reported. The letter states that an onsite inspection will be conducted within the next twelve months as required by regulation.
Report Facts
Inspection Report — Feb 7, 2017
Annual Inspection
Date: Feb 7, 2017
Visit Reason
The inspection was an annual licensing inspection conducted by the Department of Human Services to assess compliance with 55 Pa.Code Ch. 2800 relating to Assisted Living Residences.
Findings
The facility was found to be in compliance with the applicable regulations during the annual licensing inspection.
Inspection Report — Jan 13, 2017
Renewal
Date: Jan 13, 2017
Visit Reason
The document is a renewal application and license issuance for Columbia Cottage - Collegeville, LLC to operate an assisted living facility. The Department advises that an annual onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It primarily communicates the renewal of the facility's license and the requirement for a future annual inspection.
Report Facts
Inspection Report — Feb 4, 2016
Renewal
Date: Feb 4, 2016
Visit Reason
The document is a renewal license certificate and letter for Columbia Cottage - Collegeville, LLC, indicating the facility's renewal application and the Department's requirement to conduct an annual onsite inspection within the next twelve months.
Findings
No inspection findings or deficiencies are reported in this document. It serves as a license renewal confirmation and notification of future inspection requirements.
Inspection Report — Feb 1, 2016
Renewal
Date: Feb 1, 2016
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing renewal inspections on February 1 and 2, 2016, for Columbia Cottage - Collegeville, LLC.
Findings
Two violations were found related to fire drill frequency and medical evaluations. Plans of correction were submitted addressing the timing of fire drills and annual medical evaluations for residents.
Citations (2)
55 Pa.Code § 2800.132e requires a fire drill during sleeping hours every six months. The last fire drill was conducted on 11/16/15, more than six months after the previous drill on 4/29/15.
55 Pa.Code § 2800.141(b)(1) requires residents to have a medical evaluation at least annually. Resident #1's last evaluation was completed on 1/20/16, approximately one month late from the prior evaluation dated 12/10/14.
Report Facts
Number of Residents Served: 29
Number of Current Hospice Residents: 4
Number of Hospice Residents in past year: 14
Number of Residents 60 Years or Older: 29
Number of Residents with Mobility Need: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracey C. Aungst | Managing Director | Named as Administrator and legal entity representative signing plans of correction |
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