United Methodist Communities at Collingswood

In the surveyor’s words

From the most serious findings on record at United Methodist Communities at Collingswood, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF842Aug 19, 2024

  Based on interview, record review, and review of facility documents, it was determined that the facility failed to maintain medical records that were complete by not documenting the completion of treatments for 1 of 1 resident (Resident # 42) reviewed for accidents. This deficient practice was evidenced by the following: On 08/13/24 at 10:56 AM, the surveyor observed Resident #42 sitting outside his/her room in a wheelchair. The resident had a wander guard (a device that alarms if the resident attempts to exit the facility) on his/her left wrist. According to the Admission Record, Resident #42 had diagnoses which included, but were not limited to, unspecified dementia and mood disorder. […]

• No harm, potential for more than minimal, patternF880Aug 19, 2024

  Based on observations, interviews, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide a safe and sanitary environment to prevent the potential spread of infection and cross-contamination to both residents and staff by failing to: adhere to proper handwashing techniques, clean and sanitize medical equipment in accordance with the facility policy and manufacturer's recommendation and maintain appropriate infection control practices during the medication administration observation for 1 of 2 nurses observed on 1 of 3 nursing units ([NAME] Unit). This deficient practice was evidenced by the following: On 08/14/24 at 8:20 AM, the surveyor met with Registered Nurse (RN) #2 at the medication cart. […]

• No harm, potential for more than minimal, isolatedF644Nov 26, 2025

  Based on interview and record review it was determined the facility failed to conduct a new Preadmission Screening and Resident Review (PASRR) level one assessment after a resident was newly diagnosed with a mental illness. This deficient practice was identified in 1 of 1 resident reviewed for PASRR (Resident #2) and was evidenced by the following:On 11/20/2025 at 12:10 PM, the surveyor reviewed Resident #2 Electronic Medical Record (EMR) which showed that the resident had a PASRR completed on entry to the facility. Under section one for diagnoses of mental illness it was marked as NO, meaning Resident #2 did not have any mental illness diagnoses when admitted . […]

• No harm, potential for more than minimal, isolatedF657Nov 26, 2025

  Based on observation, interview, and review of pertinent facility documents it was determined the facility failed to revise an individual comprehensive care plan for a resident with a repeated fall history. This deficient practice was identified for 1 of 2 residents reviewed for falls (Resident #12) and was evidenced by the following: On 11/19/2025 at 10:24 AM, during the initial tour of the facility the surveyor observed Resident #12 in bed with eyes closed. The resident's bed was in the lowest position and there was a fall mat on the right side of the bed.A review of the admission Record face sheet (an admission summary) reflected Resident #12 was admitted to the facility with diagnoses which included but were not limited to depression, low back pain, anxiety, hypertension, and repeated… […]

• No harm, potential for more than minimal, isolatedF689Nov 26, 2025

  Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure a resident who was dependent on staff for transfers was safely and properly transferred with two staff members via mechanical lift. Instead, the resident was transferred using mechanical lift by one staff member from their chair to their bed. This deficient practice was identified for 1 of 2 residents (Resident #29) reviewed for accidents and was evidenced by the following: On 11/20/25 at 10:30 AM, Resident #29 was observed in the bed and had just received care from the Certified Nursing Assistant (CNA). The surveyor observed the resident had soft padding on the right and left upper side rails of the bed. […]