Complete Care at Mercerville LLC

Inspectors wroteBased on interviews, and review of pertinent facility documents, it was determined that the facility failed to serve and consistently document that resident's received a nourishing snack in the evening when there was more than a 14-hour span between dinner and breakfast mealtimes. This deficient practice was identified for a.) 5 of 5 alert and oriented residents (Resident's #39, #52, #81, #84, and #86) during the resident council meeting, who represented 2 of 2 units and b.) 1 of 2 residents reviewed for Nutrition (Resident #83). This deficient practice was evidenced by the following: On 4/28/25 at 8:07 AM, the surveyor conducted a kitchen tour with the Food Service Director (FSD). [...]

Inspectors wroteBased on interviews, record review, and facility documentation it was determined that the facility failed to ensure the grievance process was followed to ensure that all concerns presented by the residents were consistently addressed. This deficient practice was identified for 1of 6 residents (Resident #86) reviewed for grievances. This deficient practice was evidenced by the following: On 4/29/25 at 10:02 AM, during a resident council meeting with 5 alert and oriented residents, Resident #86 stated they were not happy with the way a nurse treated their roommate so the resident pulled the curtain back and told LPN #1 the resident is telling you the air is too much, the nurse told me to mind my f*** business, proceeded to yell at me and when she was walking out of the room, she said your moms a b****, the resident stated what did you say? LPN #1 responded you heard me. [...]

Inspectors wroteBased on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to complete a Significant Change in Status Assessment (SCSA) using the Resident Assessment Instrument (RAI) process on a resident who was discharged from hospice benefits. This deficient practice was identified for 1 of 2 residents reviewed for hospice (Resident # 20). This deficient practice was evidenced by the following: On 4/29/25 at 09:27 AM, the surveyor observed Resident #20 lying on bed watching television. The resident stated they are doing well today. A review of Resident #20's admission record revealed the resident had diagnoses which included but not limited to; diabetes (high blood sugar) and schizophrenia (a mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others). [...]

Inspectors wroteBased on observation, interview, review of medical records, other facility documentation, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 2 of 32 residents reviewed (Resident #53 and Resident #96). This deficient practice was evidenced by the following: 1. On 4/28/25 at 9:58 AM, the surveyor observed Resident #53 lying on the bed and stated they have been in the facility for 5 or 6 weeks. A review of the resident's admission record reflected the resident was admitted with diagnoses which included but not limited to; pneumonia (an infection in the lungs) and heart failure. [...]

Inspectors wroteBased on interviews and review of pertinent facility provided documents, it was determined that the facility failed to ensure the facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies was reviewed and updated, as necessary, and at least annually. This deficient practice was evidenced by the following: On 4/28/25 at 9:14 AM, during the entrance conference with the Licensed Nursing Home Administrator (LNHA), the Regional Operator (RO), the Regional Clinical Director and the Director of Nursing (DON), the surveyor requested a copy of the Facility Assessment (FA). A review of the FA revealed the following: the Persons (name/titles) involved in completing assessment: Administrator Director of Nursing Governing Body Rep (representative): [...]

Inspectors wroteBased on observations, interviews, record review, and review of pertinent facility documentation, it was determined that a facility staff member failed to ensure infection control practices were implemented by not appropriately donning (put on) and doffing (remove) Personal Protective Equipment (PPE), in accordance with accepted national standards, Centers for Disease Control and Prevention (CDC) guidelines, before and after exiting one of one resident's room, (Resident #70), who was on Transmission Based Precautions (TBP) due to a Clostridium Difficile Infection (CDI) (infectious diarrhea that can be transmitted through direct contact), on one (1) of two (2) units and perform hand hygiene to prevent the spread of infection. The deficient practice was evidenced by the following: According to the U.S. [...]

Inspectors wroteBased on interviews, review of the medical records, and other pertinent facility documents on 2/27/25 and 3/11/25, it was determined that the facility failed to maintain an accurate and complete medical record in accordance with acceptable standards and practice by not updating a resident's Comprehensive Care Plan (CPP) to include a fall and fall intervention for 1 of 3 residents (Resident #2). This deficient practice was identified for 1 of 3 residents (Resident #2) who was reviewed for falls and was evidenced by the following: According to the admission record, Resident #2 was admitted to the facility with diagnoses which included but not limited to: [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to a.) document the appropriate blood pressure (B/P) site b.) maintain ongoing consistent complete communication notes between the facility and the dialysis center post dialysis and c.) document post dialysis weight as per standards of practice. This deficient practice was identified for 1 of 1 resident reviewed for dialysis, (Resident #8), and was evidenced by the following: According to the admission Record, Resident #8 was admitted to the facility with the diagnoses which included but was not limited to: end stage renal disease (ESRD) and dependence on renal dialysis (a treatment to filter wastes and water from the blood). [...]

Inspectors wroteBased on observation, interviews and review of facility documentation it was determined that the facility failed to: a.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination and b.) maintain adequate infection control practices during food service in the kitchen. This deficient practice was observed and evidenced by the following: On 10/04/23 at 09:45 AM, the surveyor started the kitchen tour in the presence of the cook, while awaiting the arrival of the Director of Dining Services (DDS). At 09:52 AM, the surveyor was met by the Food Services Director (FSD) of a sister facility and continued the tour. The surveyor observed the following: 1. On the metal dried storage rack, there were two 6-inch-deep pans with clear liquid between them. [...]

Inspectors wroteComplaint NJ: #159452 Based on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to maintain a clean, comfortable, homelike environment. This deficient practice was identified in 2 of 50 resident rooms, for 1 of 1 resident, (Resident #44) reviewed for cleanliness of their Tube Feeding pump and pole, and on 2 of 2 nursing units. The deficient practice was evidenced by the following: 1.) On 10/04/23 at 11:36 AM, the surveyor entered room [ROOM NUMBER] and observed black scuff marks throughout the floor which resembled wheels from a wheelchair. The surveyor further observed that the heating and air conditioner unit in the room, had a perforated vent cover which was covered with a caked on brownish grey material. At that time, the surveyor observed a dead fly on the windowsill. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to conduct a new Preadmission Screening and Resident Review (PASRR) Level I 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 #70) and was evidenced by the following: On 10/05/23 at 10:09 AM, the surveyor observed Resident #70 lying in bed talking on the phone. According to the admission Record, Resident #70 had diagnoses which included: schizophrenia, post-traumatic stress disorder (PTSD), paranoid personality disorder, and depression. Review of the admission Minimum Data Set (MDS), an assessment tool utilized to facilitate care, dated 06/10/22, revealed under Section I: Active Diagnoses did not reflect an active diagnosis of schizophrenia. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) obtain a Physician's Order (PO) for a treatment after removal of a wound vac (a device that decreases air pressure on a wound which helps heal the wound faster and b.) re-apply the wound vac after it was removed by the physician. This deficient practice was identified for 1 of 23 residents, (Resident #71) reviewed for professional standards of nursing practice and was evidenced by the flowing: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; [...]

Inspectors wroteComplaint NJ: #161368 Based on observation, interview and review of the medical record, it was determined that the facility failed to provide care in a manner to maintain the grooming needs of a resident who was dependent on staff for activities of daily living and grooming. This deficient practice was identified for 1 of 23 residents reviewed, (Resident #76), and was evidenced by: According to the admission Record, Resident #76 was admitted to the facility with the diagnoses which included but was not limited to: cerebral infarction (stoke), pulmonary embolism (blood clot in the lung), and depression. The quarterly Minimum Data Set (MDS-an assessment tool utilized to facilitate care) dated 09/15/23, indicated that the resident had severe cognitive impairment and required total care with all aspects of activities of daily living (ADLs). [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to honor a resident's preference for DNR (Do Not Resuscitate), as directed on the New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) form, by performing Cardiopulmonary Resuscitation (CPR) when the resident was found unresponsive for 1 of 1 resident (Resident #102) reviewed for death. This deficient practice was evidenced by the following: According to the admission Record, Resident #102 was admitted to the facility with diagnoses which included, but were not limited to: orthopedic aftercare, acquired absence of left leg above knee, bacteremia, sepsis, candidal sepsis, unspecified severe protein-calorie malnutrition, and Methicillin Resistant Staphylococcus Aureus infection (an antibiotic resistant infection.) The resident expired three days after admission. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that an air mattress was accurately set according to the resident's weight for 1 of 1 resident (Resident #59) reviewed for pressure ulcers. This deficient practice was evidenced by the following: On 10/04/23 at 12:25 PM, 10/05/23 at 11:02 AM, and 10/06/23 at 9:42 AM, the surveyor observed Resident #59 lying in bed. The resident had an air mattress and the weight setting on the control unit was set to 350 pounds (lbs), which was the highest setting. When interviewed, the resident stated he/she had a wound that received daily wound care. [...]

Inspectors wroteBased on observation, interview, and review of facility documents, it was determined that the facility failed to ensure that the daily posted nurse staffing information was current and completed in its entirety. This deficient practice was evidence by the following: On 10/04/23 at 9:05 AM, when the survey team entered the facility, the surveyor observed the facility's Nursing Home Resident Care Staffing Report posted at the receptionist desk was dated 09/22/23 Day Shift and did not include Certified Nurse Aides (CNA) information, such as the total number of hours worked. The Staffing Report was inside of a plastic frame and there was no other Staffing Report visible at the receptionist desk. [...]

Inspectors wroteBased on observations, interviews, and a review of documentation provided by the facility, it was determined that the facility failed to maintain proper kitchen sanitation practices in a safe and sanitary environment to prevent the potential development of food-borne illness. This deficient practice was observed and was evidenced by the following: On 04/18/22 from 09:51 AM until 10:40 AM, during the initial tour of the kitchen in the presence of the Food Service Director (FSD), the surveyor observed the following: 1. The trash bucket at the handwashing sink had a broken foot pedal, causing the lid of the trash bucket to not open when stepped on. The FSD tried to fix it but said it was broken and had to be replaced. 2. The administrator entered the kitchen not wearing a hair net, leaving his black hair unrestrained. [...]

Inspectors wroteBased on observations, interviews, and review of other facility documentation, it was determined that the facility failed to ensure that mitigation measures were followed to prevent the potential spread of COVID-19, a contagious respiratory infection, by ensuring that newly admitted and readmitted residents were consistently maintained on transmission-based precautions in accordance with the facility policy and current infection control standards. This deficient practice was identified for 1 of 2 residents reviewed for transmission based precautions, (Resident #425) on 1 of 2 nursing units, South Wing and was evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and review of other facility documentation, it was determined that the facility failed to ensure that mitigation measures were followed to prevent the potential spread of COVID-19, a contagious respiratory infection, in accordance with the facility policy and current infection control standards. This deficient practice was identified for 2 of 2 unvaccinated staff, on 1 of 2 nursing units, North Wing, and was evidenced by the following: During an interview with surveyor #1 on 04/19/22 at 11:38 AM, in the presence of the survey team, the Director of Clinical Services (DCS) stated that unvaccinated staff were required to wear a surgical mask only, and no face shield or goggles were required throughout the facility as they were tested for COVID-19 weekly. [...]