Providence Place at the Collegeville Inn.

“Bottles of hand sanitizer and cleaning solution with poison warning labels were unlocked, unattended, and accessible to residents in the laundry room of the Connections secure dementia care unit. Not all residents had been assessed as capable of safely recognizing and using poisonous materials.”

“A resident's medical evaluation did not include documentation of the resident's cognitive functioning, with this area of the required form left blank.”

“Staff person A administered medications to a resident and failed to ensure the resident ingested the medications prior to documenting them as administered. Instead, the staff placed medications in a cup and left them on the counter while the resident slept, without ensuring proper administration per the prescriber's orders.”

“Staff person A documented on the medication administration record that medications were administered at 7:00 am, but at 12 pm a resident had a full medicine cup sitting on an end table. The resident indicated staff leave morning medications in a cup for the resident to take upon waking, and staff do not watch the resident ingest medications prior to initialing the MAR as administered. This is a regular occurrence.”

“Poisonous materials including X-Effect Natural Cleaner Disinfectant, Total Solutions wet wipes, and Clothesline Fresh Enzyme Spotter were found unlocked, unattended, and accessible to residents. Not all residents, including those in memory care, were assessed as capable of safely recognizing and using poisonous materials.”

“A prescription medication was found open with no open date on the label, violating manufacturer instructions for 28-day expiration after opening. Additionally, a glucagon kit for low blood sugar had an expired date and remained on the medication cart.”

“An OTC medication in the medication cart was not labeled with the resident's name and the label did not match the medication administration record.”

“A resident's glucometer was not calibrated correctly with an incorrect time display (12:35 pm instead of actual time). Additionally, a glucose reading was not documented correctly on the medication administration record.”

“Two residents prescribed glucose readings at 7:00 am were administered the readings at 10:46 am and 10:40 am respectively, failing to follow the prescriber's orders for medication timing.”

“The document text is incomplete; however, this section addresses requirements for annual training content for direct care staff, ancillary staff, substitute personnel, and regularly scheduled volunteers in areas such as fire safety and emergency preparedness.”

“A resident had an unwitnessed fall with head laceration and was transported to the hospital. The facility did not report this incident to the Department within 24 hours as required; the report was submitted approximately 13.5 hours late.”

“A resident's assessment and support plan indicated the need for assistance with nail care, but the resident did not receive this required assistance.”

“A camera in the first floor front lounge common area was recording residents, violating their right to privacy of self and possessions.”

“A direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry as required.”

“The administrator did not maintain a complete list of substitute staff persons including their telephone numbers.”

“A resident was physically struck in the face by another resident. Staff witnessed the incident where one resident punched another resident in the face/lip/chin area, resulting in visible injuries including red marks on the ear and near the lip and chin.”

“A resident's bedroom camera was recording both video and audio. Staff engaged in communication with the resident through the camera regarding medication issues, violating the resident's right to privacy during private moments.”

“Emergency evacuation diagrams were not posted on each floor showing corridors, line of travel to exit doors, and location of fire extinguishers and pull signals, despite the residence serving more than nine residents.”

“Several items containing poisonous materials were found unlocked, unattended, and accessible to residents in the Secure Dementia Care Unit, including a bottle of body wash, toothpaste tubes with poison control warnings. Residents had not been assessed as capable of safely recognizing and using poisonous materials.”

“The toilet seat in a shared resident room was smeared with fecal material and the room had sanitary condition issues at the time of inspection.”

“A medication label for a resident's tablets was inaccurate, reading "Take 1 tablet three times a day" when the current prescription dated on file was for one tablet twice a day.”

“The residence did not immediately submit a plan of supervision to the Department before returning a staff person to work following an incident where the staff member made a disrespectful comment to a resident. The staff person was brought back without Department approval.”

“A resident was not treated with dignity and respect when a staff member made a disrespectful comment in response to the resident's inappropriate language.”

“Direct care staff person B did not receive required annual training on care for residents with mental illness or intellectual disability during 2024, despite the home serving two residents with intellectual disability.”

“Sanitary conditions were not maintained in a common bathroom in the special care unit, as there was no means of hand drying available at the time of inspection.”

“A resident did not have an annual medical evaluation completed as required. The resident's previous medical evaluation was not current per regulatory requirements. This is a repeat violation.”

“The weekly menu posted in the main dining room was not current and was not posted one week in advance as required. The posted menu was for weeks that had already passed.”

“An over-the-counter medication in the special care unit medication cart was not labeled with the resident's name as required.”

“A resident using a wheelchair was transported to an event and during the return trip, the bus driver completed a sharp left turn causing the wheelchair to overturn. The resident struck their head on the metal wall of the bus and fell to the ground, suffering a head wound, neck pain, scalp abrasion, right knee pain, lumbar compression fracture, and closed head injury. The wheelchair was not securely locked or strapped to the bus, and the resident did not have a seat belt or shoulder strap.”

“During transportation of residents to a music school event, a resident in a wheelchair was not strapped or locked while the vehicle was in motion, resulting in the wheelchair overturning and injuries to the resident.”

“The first aid kit in the home's vehicle used to transport residents was not available to aid an injured resident. The facility disputed this citation, noting that the first aid kit was located on the bus and that staff members witnessed it during the incident response.”

“Directions for operating the residence's key locking mechanism were not conspicuously posted near the rear back exit door in the special care unit.”

“A resident fell out of their wheelchair when a caregiver lost control, sustaining abrasions to the face and right knee. This allegation of abuse was not reported to the local Area Agency on Aging until 8:30 PM on the same day, rather than immediately as required.”

“A resident fell out of their wheelchair and sustained abrasions to the face and right knee. The residence did not report this incident to the Department within 24 hours as required.”

“A resident fell forward out of their wheelchair when a caregiver lost control, causing multiple abrasions to the face and right knee. The resident was hospitalized for weakness and was not administered prescribed medication from specific dates through other dates, despite physician's orders to restart the medication.”

“A resident fell out of their wheelchair sustaining abrasions to the face and right knee. Staff A did not administer first aid in accordance with their training.”

“A resident prescribed medication at bedtime daily was not administered the medication during a specific time period, despite physician's orders documenting to restart the medication after a hold.”

“A resident's record does not include identifying marks as required in the content of resident records.”

“An additional written assessment was not completed for a resident whose condition significantly changed. The resident required increased observation and staff were to perform visual checks every 2 hours following altercations with other residents, but this change was not documented in an updated assessment.”

“Support plans for two residents in the special care unit for Alzheimer's disease or dementia were not reviewed quarterly as required. One resident's support plan was missing a quarterly review in June 2024, and another resident's was missing a quarterly review in May 2024.”

“Resident 5 was prescribed medication that was not administered as the medication was not available in the residence.”

“Resident 1 described pressing call pendant and experiencing excessive wait times, resulting in incontinence incidents causing embarrassment. Additionally, staff witnessed Resident 4 physically assaulting Resident 3 (smacking, kicking, arm twisting, and shaking while shouting), constituting resident-to-resident abuse.”

“Medical evaluation for Resident 4 is missing Tuberculosis skin test information and date of in-person evaluation. Medical evaluation for Resident 5 is missing Tuberculosis skin test information.”

“The residence failed to report an incident to the Department within 24 hours. Resident 1 had a fall with bruising and pain to arm, hip, and leg, but the residence did not report this incident until requested by the Department.”

“Resident 2 did not receive required assistance with Bladder and Bowel Management as indicated in their assessment and support plan.”

“Resident #1 was admitted but the in-person medical evaluation was not completed within the required 60 days prior to admission or within 15 days after admission as permitted under the applicable conditions.”

“Resident #2's resident-residence contract was signed by staff before the resident arrived at the facility. The contract was signed by the resident and designated person on a later date, but there is no indication that staff reviewed and explained the contract contents to the resident and designated person prior to signature.”

“Resident #3, who was 60 years of age or older, passed away and the residence did not provide a refund in accordance with the Elder Care Payment Restitution Act until 10/27/2023, which was untimely.”

“Resident #1 shoved resident #4, causing a fall. This was not the first incident of resident #1 pushing resident #4. Resident #1 displayed erratic and aggressive behaviors documented in progress notes. The facility failed to issue a timely 30-day notice and failed to provide additional care to keep residents safe. Additionally, resident #1 was found unescorted in resident #4's room after being moved out of the Connections secured dementia unit, and the access code had not been changed, allowing unsupervised contact and creating neglect of resident #4.”

“Three voice-controlled electronic devices were observed playing music in the hallway and dining areas. The facility lacks policies and procedures addressing these devices, including the resident's right to privacy and dignity, identification of staff with administrative access, written notification that devices may record conversations, procedures to prevent sharing of recorded conversations, and prohibition on recording without consent.”

“Poisonous materials including Dial soap and Air Wick air freshener with "Poison Control" labels were found unlocked and accessible to residents in rooms 128 and 126, and hand sanitizer bottles were found unlocked in Connections storage areas. Not all residents were assessed as capable of safely using these products.”

“A discarded Starbucks cup containing curdled milk with coffee was found in the exit area of stairwell G.”

“Resident #1 in living unit 126 had no bedside table or shelf beside their bed.”

“The residence did not provide a lockable storage unit for resident #2's medications for self-administration storage.”

“An opened and unsealed box of pancake mix and bag of flour were stored in a lower cabinet near the sink in the Connections activity kitchenette, exposing food to potential contamination.”

“An opened and unsealed box of pancake mix and bag of flour were stored in a lower cabinet near the sink in the Connections activity kitchenette instead of in closed or sealed containers.”

“One bag of confectioner's sugar and one bag of flour were found opened and undated in the kitchenette near the activities area, making it impossible to determine if they were outdated or spoiled.”

“The residence did not have documentation of written notification to the local fire department regarding the address, location of living units and bedrooms, and assistance needed to evacuate in an emergency.”

“The 2-week menu was not posted in a conspicuous and public place one week in advance, though the menu for 6/23/23 was posted in Connections.”