Inspection Reports for
United Methodist Communities At Collingswood
460 Haddon Avenue, Collingswood, NJ, 08108
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Nov 26, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to pre-admission screening, care planning, and safe resident transfers at the nursing home.
Findings
The facility was found deficient in conducting a new PASRR level one assessment after a resident was newly diagnosed with a mental illness, failing to revise an individual comprehensive care plan following repeated falls for a resident, and not ensuring safe mechanical lift transfers requiring two staff members, resulting in minimal harm or potential for actual harm to residents.
Deficiencies (3)
Failed to conduct a new PASRR level one assessment after a resident was newly diagnosed with a mental illness.
Failed to revise an individual comprehensive care plan for a resident with a repeated fall history within 7 days of the comprehensive assessment.
Failed to ensure a resident dependent on staff for transfers was safely transferred with two staff members via mechanical lift; transferred by one staff member instead.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Dates of falls: 3
Brief Interview of Mental Status (BIMS) scores: 0
Brief Interview of Mental Status (BIMS) scores: 4
Brief Interview of Mental Status (BIMS) scores: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding PASRR, care plan updates, and mechanical lift incident | |
| Licensed Nursing Home Administrator | Interviewed regarding PASRR policy and procedures |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 26, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding the improper transfer of a resident who required two staff members for mechanical lift transfers but was transferred by only one staff member.
Complaint Details
The complaint investigation found that Resident #29 was transferred alone by one CNA instead of two as ordered, resulting in an injury to the resident's wrist. The CNA was suspended. The injury was not fall-related but likely caused by hitting the bed rail.
Findings
The facility failed to ensure safe transfer of Resident #29 who required two-person mechanical lift assistance, resulting in a wrist injury likely caused by hitting the bed rail. The CNA did not follow the care plan or physician orders and was suspended. The facility policy requires two persons for mechanical lift transfers.
Deficiencies (1)
Failure to ensure a resident dependent on two-person mechanical lift transfers was transferred safely by only one staff member.
Report Facts
Residents Affected: 1
Date of incident: Sep 30, 2025
Date of survey completion: Nov 26, 2025
Notice
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice explains the types of information covered, reasons for use and disclosure of health information, legal duties of NJDHSS, and the rights of individuals to access, amend, and restrict their health information.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Routine
Deficiencies: 3
Date: Aug 19, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care planning, medical record maintenance, and infection prevention and control practices at United Methodist Communities at Collingswood.
Findings
The facility was found deficient in developing comprehensive care plans for residents, maintaining complete medical records with proper documentation of treatments, and implementing effective infection prevention and control practices, including hand hygiene and cleaning of medical equipment between resident uses.
Deficiencies (3)
Failure to develop a comprehensive person-centered care plan including continuous oxygen therapy for Resident #36.
Failure to maintain complete medical records by not documenting completion of wander guard treatment for Resident #42.
Failure to provide and implement an infection prevention and control program, including improper hand hygiene and failure to clean medical equipment between residents.
Report Facts
Residents affected: 1
Residents affected: 1
Nurses observed: 2
Dates with unsigned TAR entries: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding care plan deficiencies for Resident #36 |
| RN #2 | Registered Nurse | Observed and interviewed regarding infection control deficiencies during medication administration |
| RN #3 | Registered Nurse | Interviewed regarding infection control practices and cleaning protocols |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding care plan and infection control deficiencies |
| Certified Nursing Assistant | CNA | Interviewed regarding wander guard checks |
| Licensed Practical Nurse | LPN | Interviewed regarding wander guard checks and documentation |
| Staff Educator | Staff Educator (SE) | Interviewed regarding hand hygiene and infection control policies |
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 4
Date: Feb 2, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ00131702 and NJ00158881 regarding medication management and administration at the facility.
Complaint Details
The complaint investigation was substantiated based on findings related to medication errors and failure to follow medication management policies for Resident #2.
Findings
The facility was found not in substantial compliance with New Jersey Administrative Code standards, specifically failing to ensure proper medication management and administration for Resident #2, including failure to notify physicians about unavailable medications and failure to report a medication error timely to the Department of Health.
Deficiencies (4)
Failure to ensure the Medication Management Program Guidelines were implemented for Resident #2, including documentation and administration of medications.
Failure to provide care and services in accordance with physician's orders for medication administration for Resident #2.
Failure to immediately report a medication error to the Department of Health, resulting in a change in medical condition and hospitalization for Resident #2.
Failure to administer medications according to prescriber orders and facility policy.
Report Facts
Census: 94
Sample Size: 8
Days medication not administered: 10
Days medication not administered (total): 14
Completion Date: 2024
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 19, 2023
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at the nursing home.
Findings
No health deficiencies were found during the inspection.
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