Inspection Reports for Columbia Cottage-Collegeville, LLC
901 E. MAIN STREET, COLLEGEVILLE, PA, 19426
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
8.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
83% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
46% occupied
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Census: 23
Capacity: 50
Deficiencies: 10
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.
Deficiencies (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
License Capacity: 50
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
Monitoring
Census: 23
Capacity: 50
Deficiencies: 9
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.
Deficiencies (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
License Capacity: 50
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
Follow-Up
Census: 28
Capacity: 50
Deficiencies: 4
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.
Deficiencies (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
License Capacity: 50
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
Inspection Report
Renewal
Census: 29
Capacity: 50
Deficiencies: 10
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.
Deficiencies (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
License Capacity: 50
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
Renewal
Census: 24
Capacity: 50
Deficiencies: 0
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
License Capacity: 50
Current Hospice Residents: 4
Resident Support Staff Hours: 0
Total Daily Staff Hours: 40
Waking Staff Hours: 30
Inspection Report
Renewal
Census: 28
Capacity: 50
Deficiencies: 9
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.
Deficiencies (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
License Capacity: 50
Residents Served: 28
Total Daily Staff: 44
Waking Staff: 33
Hospice Residents: 4
Residents with Mobility Need: 16
Inspection Report
Renewal
Census: 32
Capacity: 50
Deficiencies: 1
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.
Deficiencies (1)
On 3/31/21, resident #1's glucometer reading was 173, but 174 was documented on the medication administration record.
Report Facts
License Capacity: 50
Residents Served: 32
Current Hospice Residents: 4
Resident Mobility Need: 15
Notice
Capacity: 50
Deficiencies: 0
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
Maximum capacity: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
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