Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at United Methodist Communities At Collingswood during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions, who required two-person assistance for mechanical lift transfers, was transferred by only one CNA, contrary to physician orders and facility policy. The resident later experienced wrist pain, with investigation revealing the injury likely occurred when the resident struck the bed rail, and not due to a fall.
A resident’s PASRR was completed on admission and showed no mental illness diagnosis, but later records documented psychotic disorder/psychosis and severe cognitive impairment. The facility did not complete a new PASRR level one assessment after the new psychiatric diagnosis was identified, and the LNHA stated there was no PASRR policy in place.
Failure to revise a fall-risk care plan after repeated falls. A resident with severe cognitive impairment, repeated falls, and diagnoses including depression, anxiety, HTN, and low back pain had unwitnessed falls with injuries including a forehead laceration, knee pain, and a skin tear, with one event resulting in hospital transfer. The existing ICCP included basic fall precautions, but it was not updated with new interventions after the falls, and the DON acknowledged the care plan was not revised after each event.
A resident with severe cognitive impairment and a high risk for wandering had incomplete documentation of wander guard checks in their medical records. Despite the care plan requiring checks every shift, the Treatment Administration Record showed multiple instances where these checks were not documented. Interviews with facility staff confirmed the lapses in documentation, and the facility lacked a policy on medical documentation.
A registered nurse in a long-term care facility failed to adhere to infection control practices by not performing proper hand hygiene and not cleaning medical equipment between resident uses. The nurse handled a glucometer test strip without gloves and did not disinfect the blood pressure machine, pulse oximeter, and glucometer, leading to potential cross-contamination.
A resident with multiple medical conditions, including heart failure and sleep apnea, was receiving continuous oxygen therapy, but this was not included in their care plan. Facility staff confirmed the omission, which was against the facility's policy requiring comprehensive care plans.
Failure to Follow Two-Person Mechanical Lift Transfer Protocol
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for transfers was not safely and properly transferred according to their care plan and physician orders. The resident, who had diagnoses including dementia, urinary retention, failure to thrive, and severe cognitive impairment, required a mechanical lift with assistance from two staff members for all transfers. However, on one occasion, the resident was transferred from a wheelchair to a bed using a mechanical lift by only one CNA, contrary to the established plan of care and facility policy. The resident's spouse was present during the transfer, which was described as uneventful, and there was no witnessed fall. Subsequently, the resident was found to have pain in the right wrist, and an X-ray was ordered. The facility's investigation concluded that the injury was not related to a fall but likely occurred when the resident struck the bed rail. Review of facility documentation, including the Minimum Data Set, physician orders, and the care plan, confirmed that the resident required two-person assistance for transfers with a mechanical lift. The facility's policy also specified that two persons are required for mechanical lift usage, which was not followed in this instance.
Failure to Update PASRR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to conduct a new PASRR level one assessment after a resident was newly diagnosed with a mental illness. The resident had a PASRR completed on admission in February 2023, and the initial PASRR indicated no mental illness diagnoses at that time. The resident’s admission diagnoses included pain, anxiety, Parkinson’s disease, diabetes, and muscle weakness. Review of the resident’s records showed that the most recent quarterly MDS dated 9/4/25 documented a BIMS score of 00 out of 15 and listed psychotic disorder as an active diagnosis. A prior quarterly MDS dated 12/15/23 did not mark psychotic disorder as an active diagnosis. The resident’s most recent psychiatric note dated 10/22/25 also listed psychosis. During interviews, the DON stated the Social Worker was responsible for PASRR, and the LNHA stated the facility did not have a PASRR policy and said PASRR should be completed on admission or if a resident is prescribed an antipsychotic or receives a new psychiatric diagnosis.
Failure to Revise Fall-Risk Care Plan After Repeated Falls
Penalty
Summary
The facility failed to revise the individualized comprehensive care plan for a resident with a repeated fall history. Resident #12 was admitted with diagnoses including depression, low back pain, anxiety, hypertension, and repeated falls, and the most recent quarterly MDS dated 10/15/25 showed severe cognitive impairment with a BIMS score of 4/15 and substantial/maximum assistance needed for sit-to-stand transfers. The resident was observed in bed with the bed in the lowest position and a fall mat on the right side of the bed during the initial tour. Review of incident reports and progress notes showed unwitnessed falls on 1/17/25, 2/17/25, and 7/25/25. The resident was found on the floor with a small forehead laceration after the first fall, found on the bathroom floor after stating they fell out of bed during the second fall, and found on the floor next to the bed with a skin tear to the left lower jaw area after the third fall, which resulted in transfer to the hospital for evaluation. The resident’s fall-risk care plan, initiated on 10/23/23, included interventions such as assessing call light ability, not leaving the resident alone in the bathroom, educating on calling for assistance, keeping items within reach, and keeping the room free of clutter, but it did not include new interventions after the three falls. The DON acknowledged that the care plan was not updated following each fall, and the facility policy stated that the care plan would be modified as indicated after a fall and updated for significant changes.
Incomplete Documentation of Wander Guard Checks
Penalty
Summary
The facility failed to maintain complete medical records for a resident identified as being at high risk for wandering. The resident, who had severe cognitive impairment due to unspecified dementia and a mood disorder, was observed with a wander guard on their left wrist. The resident's care plan included interventions to prevent elopement, such as ensuring the wander guard was in place and functioning. However, the Treatment Administration Record (TAR) for May, June, and August 2024 showed multiple instances where the required checks for the wander guard's placement and function were not documented, indicating that the treatments were not completed as ordered. Interviews with facility staff, including a CNA, LPN, RN, and the Director of Nursing, confirmed that the responsibility for checking and documenting the wander guard's status every shift was not consistently fulfilled. The staff acknowledged the importance of these checks to prevent elopement but admitted that blanks in the TAR meant the checks were not documented. The facility was unable to provide a policy related to medical documentation or the TAR, further highlighting the deficiency in maintaining complete medical records for the resident.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by the actions of a registered nurse (RN) during medication administration and resident care. The RN did not adhere to proper hand hygiene protocols, failing to wash hands after removing gloves and before handling medication cart keys, accessing the computer, and interacting with residents. This lapse in hand hygiene occurred multiple times during the observation, including after touching a resident's mask and before preparing medications. Additionally, the RN did not clean and disinfect medical equipment between resident uses, such as the blood pressure machine, pulse oximeter, and glucometer. The RN used these devices on multiple residents without cleaning them with disinfectant wipes, which is against the facility's policy and the manufacturer's recommendations. The RN also handled a used glucometer test strip without gloves, further increasing the risk of cross-contamination. The Director of Nursing (DON) and Staff Educator (SE) confirmed that these actions were against the facility's infection control policies. The DON acknowledged that the RN did not clean the glucometer after use, and the SE emphasized the importance of cleaning equipment between residents to prevent contamination. The facility's policies require hand hygiene before and after resident contact and the cleaning of equipment with disinfectant wipes between uses, which were not followed in this instance.
Failure to Include Oxygen Therapy in Resident's Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident who was receiving continuous oxygen therapy. The resident, who had a range of medical conditions including cardiac pacemaker presence, chronic atrial fibrillation, chronic pulmonary edema, heart failure, and obstructive sleep apnea, was observed receiving oxygen via a nasal cannula. Despite these conditions and the active physician's order for continuous oxygen therapy, the resident's care plan did not include the use of oxygen, which is a critical component of their treatment. Interviews with facility staff, including a registered nurse, the MDS coordinator, and the Director of Nursing, confirmed that the omission of oxygen therapy from the care plan was not in line with the facility's policy and procedure. The staff acknowledged that the care plan should have been updated to include the resident's oxygen needs to ensure all caregivers, including agency nurses, were aware of the resident's requirements. The facility's policy mandates that care plans be comprehensive and individualized, integrating all necessary medical and clinical supports, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Collingswood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River Front Rehabilitation And Healthcare Center | 0.7 mi | ★★★★★ | 23 | 0 |
| Majestic Center For Rehab & Sub-acute Care | 2.4 mi | ★★★★★ | 3 | 0 |
| Aristacare At Cherry Hill | 2.5 mi | ★★★★★ | 21 | 0 |
| Abigail House For Nursing & Rehabilitation | 2.7 mi | ★★★★★ | 0 | 0 |
| Premier Cadbury Of Cherry Hill | 3.2 mi | ★★★★★ | 27 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.