Inspection Reports for Providence Place Senior Living at the Collegeville Inn
4000 Ridge Pike, Collegeville, PA 19426, United States, PA, 19426
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20
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10
5
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Census Over Time
Census
Capacity
Inspection Report
Follow-Up
Census: 116
Capacity: 150
Deficiencies: 3
Aug 28, 2025
Visit Reason
The inspection was a partial, unannounced visit conducted due to a complaint and incident reported at the facility.
Findings
The inspection identified deficiencies related to abuse/neglect, privacy violations involving unauthorized audio-video recording, and missing emergency evacuation diagrams. Plans of correction were accepted and implemented by the facility.
Complaint Details
The visit was complaint-related due to an incident where one resident physically abused another. The Executive Director and Connections Director reported the incident to DHS and Area Agency on Aging, which conducted an investigation with no findings or follow-up required.
Deficiencies (3)
| Description |
|---|
| Resident was physically abused by another resident, resulting in injuries and distress. |
| Resident had a camera in their room recording video and audio, violating privacy rights. |
| No emergency evacuation diagrams posted on each floor showing line of travel to exit doors. |
Report Facts
Residents served: 116
License capacity: 150
Special care unit capacity: 47
Special care unit residents served: 31
Hospice current residents: 13
Residents aged 60 or older: 116
Residents with mental illness: 1
Residents with intellectual disability: 1
Residents with mobility need: 53
Inspection Report
Complaint Investigation
Census: 106
Capacity: 150
Deficiencies: 3
Jun 25, 2025
Visit Reason
The inspection was conducted as a complaint investigation, with an unannounced partial inspection to review compliance and follow up on a plan of correction.
Findings
The inspection identified deficiencies related to unsecured poisonous materials accessible to residents in the Secure Dementia Care Unit, unsanitary bathroom conditions in a shared resident room, and improperly labeled resident medications. Plans of correction were accepted and implemented with staff training and ongoing monitoring.
Complaint Details
The visit was complaint-related as stated under Inspection Information with Reason: Complaint. The plan of correction was fully implemented as of 06/25/2025.
Deficiencies (3)
| Description |
|---|
| Several items containing poisonous materials were unlocked, unattended, and accessible to residents in the Secure Dementia Care Unit. |
| The toilet seat in a shared resident bathroom was smeared and the bathroom needed attention. |
| The label on a resident's medication tablets did not match the current prescription dosage. |
Report Facts
License Capacity: 150
Residents Served: 106
Special Care Unit Capacity: 47
Special Care Unit Residents Served: 34
Hospice Current Residents: 11
Residents Age 60 or Older: 106
Residents with Mental Illness: 1
Residents with Intellectual Disability: 1
Residents with Mobility Need: 53
Inspection Report
Follow-Up
Census: 106
Capacity: 150
Deficiencies: 11
Apr 17, 2025
Visit Reason
The inspection was a partial, unannounced visit conducted due to a complaint and incident, with the purpose of reviewing compliance and the submitted plan of correction.
Findings
The report details multiple deficiencies related to staff supervision, dignity and respect, training, sanitary conditions, medical evaluations, menu posting, medication labeling, following prescriber orders, support plan signatures, and preadmission screening. All deficiencies had plans of correction accepted and were implemented by June 6, 2025.
Complaint Details
The inspection was complaint-related and incident-driven, with a follow-up on the submitted plan of correction.
Deficiencies (11)
| Description |
|---|
| Failure to submit a supervision plan immediately after an incident involving staff behavior. |
| Resident was treated without dignity and respect, including use of inappropriate language by staff. |
| Direct care staff did not receive required training on care for residents with mental illness or intellectual disability. |
| No means of hand drying in one of the common bathrooms in the special care unit. |
| Resident's annual medical evaluation was not completed due to resident passing away; audit found no missing evaluations for others. |
| Menus posted were not current or posted one week in advance as required. |
| Over-the-counter medication package in special care unit medication cart was not labeled with resident's name. |
| Medications were administered before the previous order was completed and not at prescribed times. |
| Support plans for residents were not signed by the assessor. |
| Resident's medical evaluation did not include diagnosis or need for special care unit placement. |
| Resident's written cognitive preadmission screening was not completed. |
Report Facts
License Capacity: 150
Residents Served: 106
Special Care Unit Capacity: 47
Special Care Unit Residents Served: 32
Hospice Current Residents: 14
Residents with Mobility Need: 47
Residents 60 Years or Older: 106
Residents Diagnosed with Intellectual Disability: 2
Resident Diagnosed with Mental Illness: 0
Resident with Physical Disability: 0
Total Daily Staff: 153
Waking Staff: 115
Inspection Report
Follow-Up
Census: 119
Capacity: 150
Deficiencies: 4
Mar 26, 2025
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident involving a resident who was injured during transportation. The visit included a plan of correction submission and follow-up reviews.
Findings
The facility was found to have multiple deficiencies related to abuse/neglect, safety restraints, transportation first aid kit availability, and key locking devices. The resident was injured due to an unsecured wheelchair during transport. The facility implemented corrective actions including staff training, equipment checks, and audits.
Deficiencies (4)
| Description |
|---|
| A resident was injured when a wheelchair overturned on a bus due to the wheelchair not being securely locked or strapped, and the resident not having a seat belt or shoulder strap. |
| The vehicle used to transport residents did not have appropriate safety restraints securing the wheelchair while the vehicle was in motion, resulting in injury. |
| The first aid kit in the home's van was reported as not available to aid an injured resident, though the bus did have a first aid kit. |
| Directions for operating the residence's locking mechanism were not conspicuously posted near the rear back exit door in the special care unit. |
Report Facts
License Capacity: 150
Residents Served: 119
Special Care Unit Capacity: 47
Special Care Unit Residents Served: 32
Current Hospice Residents: 13
Residents Diagnosed with Mental Illness: 8
Residents Diagnosed with Intellectual Disability: 8
Residents with Mobility Need: 47
Residents Age 60 or Older: 119
Total Daily Staff: 166
Waking Staff: 125
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Driver of the bus involved in the incident causing resident injury; placed on leave and later terminated for failure to follow code of conduct | |
| Staff B | Direct staff aide who assisted with loading the resident onto the bus and reported on the incident | |
| Director of Nursing | Director of Nursing | Ensured first aid kit replenishment and infection control; involved in audits of first aid kits |
| Maintenance Director | Maintenance Director | Evaluated wheelchair straps on the bus and provided training to community drivers |
| Executive Director | Executive Director | Reposted locking mechanism code and audited exterior doors for compliance |
| Connections Director | Connections Director | Assessed incident on the bus and witnessed presence of first aid kit |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 150
Deficiencies: 0
Feb 5, 2025
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 150
Residents Served: 126
Special Care Unit Capacity: 47
Special Care Unit Residents Served: 33
Hospice Current Residents: 11
Residents Age 60 or Older: 126
Residents Diagnosed with Mental Illness: 6
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 52
Residents with Physical Disability: 1
Inspection Report
Census: 107
Capacity: 150
Deficiencies: 0
Oct 10, 2024
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, on 10/10/2024.
Findings
No regulatory citations or deficiencies were identified during this licensing inspection.
Report Facts
Residents Served: 107
License Capacity: 150
Special Care Unit Capacity: 47
Special Care Unit Residents Served: 33
Current Hospice Residents: 9
Residents Age 60 or Older: 107
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 44
Inspection Report
Complaint Investigation
Census: 112
Capacity: 150
Deficiencies: 6
Sep 10, 2024
Visit Reason
The inspection was conducted as a complaint investigation following allegations related to resident abuse and incident reporting failures.
Findings
The facility was found to have failed to immediately report a resident fall resulting in injury, delayed reporting to the Department, and deficiencies in following prescriber’s orders and providing first aid. Multiple corrective actions and education plans were implemented and accepted.
Complaint Details
The complaint involved allegations of resident abuse due to a fall from a wheelchair and failure to report the incident timely to the local Area Agency on Aging and the Department. The complaint was substantiated with findings of delayed reporting and neglect.
Deficiencies (6)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident following a fall causing abrasions. |
| Failure to report an incident to the Department within 24 hours as required. |
| Resident was neglected when caregiver lost control of wheelchair causing injury and failure to administer prescribed medication as ordered. |
| Staff did not provide first aid in accordance with training after resident sustained injuries from a fall. |
| Failure to follow prescriber’s orders regarding medication administration. |
| Resident records did not include identifying marks as required. |
Report Facts
License Capacity: 150
Residents Served: 112
Special Care Unit Capacity: 47
Special Care Unit Residents Served: 34
Hospice Current Residents: 10
Residents Age 60 or Older: 112
Staff Total Daily: 146
Staff Waking: 110
Audit Frequency: 5
Audit Duration Weeks: 4
Mentor Days: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person B | Named in findings related to failure to report abuse, re-education, mentoring, and written coaching | |
| Staff person A | Named in findings related to loss of control of wheelchair and failure to provide first aid | |
| Executive Director | Responsible for initiating investigations, submitting reports, auditing incidents, and providing education | |
| Director of Nursing | Involved in re-education of staff and auditing medication administration |
Inspection Report
Monitoring
Census: 109
Capacity: 150
Deficiencies: 2
Jul 2, 2024
Visit Reason
The inspection was conducted as a partial, unannounced visit for incident and monitoring purposes at Providence Place at the Collegeville Inn.
Findings
The report found deficiencies related to resident assessments and support plan reviews, specifically missing additional written assessments after significant resident condition changes and lack of timely quarterly reviews for residents in the special care unit. Plans of correction were submitted and fully implemented by October 17, 2024.
Deficiencies (2)
| Description |
|---|
| Resident assessment did not include required increased observation and visual checks every 2 hours following altercations; an additional written assessment was not completed. |
| Support plans for residents in the special care unit lacked required quarterly reviews in May and June 2024. |
Report Facts
License Capacity: 150
Residents Served: 109
Special Care Unit Capacity: 47
Special Care Unit Residents Served: 32
Hospice Current Residents: 10
Residents Age 60 or Older: 108
Residents with Intellectual Disability: 1
Residents with Mobility Need: 35
Inspection Report
Complaint Investigation
Census: 107
Capacity: 150
Deficiencies: 5
Apr 29, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at Providence Place at the Collegeville Inn.
Findings
The inspection identified multiple deficiencies including failure to report an incident within 24 hours, inadequate assistance with activities of daily living, resident-to-resident abuse, incomplete medical evaluations, and failure to follow prescriber's orders. Plans of correction were accepted and implemented by August 8, 2024.
Complaint Details
The visit was complaint-related, investigating incidents including a resident fall not reported timely, inadequate assistance with ADLs, resident-to-resident abuse, incomplete medical evaluations, and medication administration errors. The complaint was substantiated with multiple deficiencies found.
Deficiencies (5)
| Description |
|---|
| Failure to report a resident fall with bruising and pain to the Department within 24 hours. |
| Resident did not receive required assistance with bladder and bowel management as indicated in their assessment and support plan. |
| Resident-to-resident abuse including physical aggression and neglect in responding to call pendants causing embarrassment and distress. |
| Medical evaluations for residents lacked required Tuberculosis skin test information and date of in-person evaluation. |
| Medication prescribed to a resident was not administered due to unavailability in the residence. |
Report Facts
License Capacity: 150
Residents Served: 107
Special Care Unit Capacity: 47
Special Care Unit Residents Served: 32
Current Hospice Residents: 8
Residents Age 60 or Older: 107
Residents with Mobility Need: 32
Inspection Report
Renewal
Census: 96
Capacity: 150
Deficiencies: 16
Nov 13, 2023
Visit Reason
The inspection was conducted as a renewal visit with an incident review, including a full unannounced inspection on 11/13/2023 and 11/14/2023.
Findings
The inspection identified multiple deficiencies including issues with resident abuse/neglect, privacy violations, medication storage and administration, fire drill scheduling, resident assessments, and documentation. Plans of correction were accepted and implemented with follow-up audits scheduled.
Deficiencies (16)
| Description |
|---|
| Resident #1's medical evaluation was not completed as required within the specified timeframe. |
| Resident #2's residence contract was not signed by the resident or designated person prior to admission. |
| The residence did not provide a timely refund in accordance with the Elder Care Payment Restitution Act after the death of a resident over 60 years old. |
| Resident #1 was neglected by allowing access to secured dementia care unit and unsupervised visits despite aggressive behavior. |
| Privacy violations due to lack of policies and procedures for voice-controlled electronic devices playing music in common areas. |
| Staff person B did not complete required orientation training within 40 scheduled working hours. |
| Food was stored uncovered and undated in the kitchen. |
| Fire drills were held on the same day of the week multiple times, not meeting scheduling requirements. |
| Medication prescribed to resident #4 was not available in the residence, leading to missed doses. |
| Staff persons C and D did not maintain compliance with annual medication administration course requirements. |
| Staff persons C and D administered insulin without completing required diabetes patient education program within the past 12 months. |
| Resident #1 exhibited aggressive behaviors without implementation of positive interventions to modify or eliminate behavior. |
| Initial assessments for residents #1 and #7 were not completed timely prior to or shortly after admission. |
| Preliminary support plan for resident #2 was not signed and dated by all participants in a timely manner. |
| Resident #7's most recent annual assessment was not completed within the required timeframe. |
| Written cognitive preadmission screenings for residents #2, #4, and #8 were not completed within 72 hours prior to admission to the special care unit. |
Report Facts
Residents served: 96
License capacity: 150
Memory care capacity: 41
Memory care residents served: 32
Hospice current residents: 8
Residents age 60 or older: 96
Residents with mobility need: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person B | Named in deficiency for incomplete orientation training within 40 scheduled working hours | |
| Staff person C | Named in deficiencies for noncompliance with medication administration course and diabetes education program | |
| Staff person D | Named in deficiencies for noncompliance with medication administration course and diabetes education program | |
| Staff member E | Connections Program Director | Named in deficiency for not signing preliminary support plan |
| Staff member F | Named in deficiency for not signing preliminary support plan and not listed on Master Employee List | |
| Dean Gray | Lead Inspector | Lead inspector for the inspection |
Inspection Report
Plan of Correction
Census: 86
Capacity: 150
Deficiencies: 12
Jun 23, 2023
Visit Reason
The inspection was a partial, announced visit conducted as a new inspection to review compliance and the implementation of a submitted plan of correction.
Findings
Multiple deficiencies were identified including unlocked poisonous materials accessible to residents, sanitary issues, lack of bedside tables, unprotected and improperly stored food, missing fire department notification documentation, medication storage issues, and missing directions for key-locking devices. All deficiencies had accepted plans of correction with completion dates in late June 2023 and implementation by July 2023.
Deficiencies (12)
| Description |
|---|
| Unlocked poisonous materials accessible to residents in multiple rooms and storage areas. |
| Discarded Starbucks cup containing curdled milk found in stairwell exit area. |
| No bedside table or shelf beside resident #1's bed in living unit 126. |
| Opened and unsealed box of pancake mix and bag of flour stored in kitchenette cabinet. |
| Opened and unsealed box of pancake mix and bag of flour stored in kitchenette cabinet (repeated). |
| Opened and undated bag of confectioner's sugar and bag of flour found in kitchenette. |
| No documentation of written notification to local fire department regarding residence address, living units, and evacuation assistance. |
| Two-week menu not posted as required. |
| No lockable storage unit provided for resident #2's medications. |
| Three tubes of medication cream unlocked and accessible at bedside in room 128. |
| Prescribed insulin for resident #2 unlocked and accessible in shared refrigerator. |
| Directions for operating locking mechanism not conspicuously posted near stair F exit in special care unit. |
Report Facts
Residents Served: 86
License Capacity: 150
Special Care Unit Capacity: 41
Special Care Unit Residents Served: 26
Hospice Current Residents: 9
Residents Age 60 or Older: 86
Residents with Mobility Need: 39
Total Daily Staff: 125
Waking Staff: 94
Inspection Report
Renewal
Census: 47
Capacity: 150
Deficiencies: 20
Apr 12, 2021
Visit Reason
The inspection was a full, unannounced renewal inspection conducted on April 12 and 13, 2021 to assess compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including failure to post required telephone numbers, unlocked poisonous materials accessible to residents, unsanitary conditions in resident bathrooms, missing emergency telephone numbers by resident phones, improper food storage and outdated food items, incomplete medical evaluations, medication administration errors, and incomplete support plans. Plans of correction were accepted and fully implemented by August 8, 2022.
Deficiencies (20)
| Description |
|---|
| Telephone numbers of the Department’s personal care home regional office, local ombudsman, protective services, law enforcement, and complaint hotline were not posted in a conspicuous and public place. |
| Colgate toothpaste with poison warning label was unlocked and accessible to residents not assessed capable of safely using poisons. |
| Sanitary conditions not maintained: bathroom shared by two residents had feces splashed on toilet bowl and commingled personal items. |
| No emergency telephone numbers posted on or by telephones in resident rooms. |
| Food not protected from contamination: uncovered tray of bread pudding in kitchen refrigerator. |
| Food not stored in closed or sealed containers: opened and unsealed bags of granola in dry storage. |
| Outdated or spoiled food present: unlabeled, undated granola bags and unlabeled frozen food items. |
| Written emergency procedures not reviewed, updated, or submitted since September 2019. |
| Medical evaluation for resident #1 missing indication of tuberculin skin test or chest X-ray. |
| First aid kit in resident transport bus missing breathing shield. |
| Medication administration error: Tramadol signed out but administered more than 5 hours later. |
| Current medications violation: Ativan prescribed for 14 days in 2020 still present in med cart in 2021. |
| Glucometer for resident #4 not calibrated to correct date and time. |
| Medication procedures violation: controlled substance log not completed timely during med pass. |
| Medication record missing diagnosis for prescribed ABHR Gel for resident #5. |
| Final support plans for residents #6 and #7 did not address use of bed enabler. |
| Support plans for residents #6 and #8 not signed by assessor. |
| Resident #1 medical evaluation completed in 2019 but admitted later. |
| Resident #9's cognitive preadmission screening incomplete regarding residence's ability to meet needs. |
| Direct care staff person B completed only 3.5 hours of required 8 hours dementia training within first 30 days of hire. |
Report Facts
License Capacity: 150
Residents Served: 47
Special Care Unit Capacity: 41
Special Care Unit Residents Served: 20
Hospice Residents: 5
Resident Mobility Need: 24
Resident Age 60 or Older: 46
Residents Diagnosed with Mental Illness: 2
Inspection Report
Renewal
Capacity: 150
Deficiencies: 0
Oct 19, 2021
Visit Reason
The document is a renewal license issued in response to the facility's October 12, 2021 renewal application to operate the Assisted Living Home pursuant to Title 55, PA Code, Chapter 2800.
Findings
A regular license is being issued based on the renewal application. The Department will conduct an onsite inspection within the next twelve months as required by regulation, and enforcement action will be taken if noncompliance is found.
Report Facts
Maximum licensed capacity: 150
Special Care Unit capacity: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal license letter |
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