Preferred Care at Mercer

Inspectors wroteBased on observation, record review, interviews, and facility policy review the facility failed to implement pharmacy processes for labeling medications, including controlled substances (CS), for four of four medication carts (Medication Carts One and Two on [NAME] Unit; Medication Carts One and Two on Ewing Unit) observed for medication storage and labeling of 27 sample residents. This failure had the potential risk of drug diversion, theft, improper handling of returns, all impacting patient safety and compliance.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to prevent the build-up of grease, food crumbs, and dirt on fixed equipment, behind cooking equipment and on walls and floors for one of one kitchen, as well as failing to clean and maintain two of three ice machines in the facility. This deficient practice had the potential to affect 84 of 84 residents who received meals and beverages prepared in and served from the facility's kitchen and pantries.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure Notice of Medicare Non-Coverage (NOMNOC) notification was provided timely for two of three residents (Resident 5 and R32) reviewed for beneficiary notification of 27 sample residents. This had the potential to affect all residents being discharged from services.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to develop a care plan for one of two residents (Resident (R) 11) reviewed for behavioral-emotional status of 27 sample residents. This failure could interfere with the resident receiving proper psychological services to help maintain a comfortable, safe life.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure residents who were assessed as requiring an apron were provided with an apron while smoking for one of two residents (Resident (R) 105) reviewed for smoking out of 27 sampled residents. This has the potential to affect all residents who smoke.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure residents received alternative measures prior to the installation of side rails; for one of four residents (Resident (R) 105) reviewed for side rails out of 27 sampled residents. The lack of alternate side rail measures and proper assessment/consent could lead to potential restraint or side rail entrapment.

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide necessary treatment and services as ordered by the physician to promote the healing of a wound. The deficient practice was identified for 3 of 3 residents (Resident #1, #2, and #3) reviewed for wound care. The deficient practice was evidenced by the following: A review of Resident #1 admission Record revealed medical diagnosis which included but not limited to dementia and chronic kidney disease. Review of the most recent quarterly Minimum Data Set (MDS), an assessment tool revealed the resident had a Brief Interview of Mental Status (BIMS) of 12, meaning the resident had moderate cognitive impairment. A review of the physician orders showed the following order: [...]

Inspectors wroteComplaint #:2575153 Based on observation, interviews, medical record review, and review of pertinent facility documents, it was determined that the facility failed to administer medications with less than a 5% medication error rate. The surveyor observed one nurse administer medications to four residents with a total of 43 opportunities. Three errors were observed, which calculated to a medication administration error rate of 6.97%. This deficient practice was identified for two of four residents that were administered medications by 1 nurse on the first-floor sub-acute nursing unit. This deficient practice was evidenced by the following: 1.) On 08/01/2025 at 8:45 A.M., the surveyor observed the Registered Nurse (RN #1) preparing and administering medications for an unsampled resident. [...]

Inspectors wroteComplaint #: 2575153 Based on interviews, record review, and review of other pertinent facility documents on 08/01/2025, it was determined that the facility failed to ensure that a resident (Resident #2) received the correct intravenous (IV) antibiotic medication. This deficient practice was identified for one of three residents reviewed for medication errors and was evidenced by the following: According to the admission Record (AR), Resident #2 was admitted to the facility with diagnoses including but not limited to peritoneal abscess (pocket of pus and infected fluid in the tissue lining the abdomen); sepsis (life-threatening condition caused by the body's response to an infection), unspecified organism; bacteremia (bacteria in the blood); pneumonia (inflammation and fluid in the lungs), unspecified organism; [...]

Inspectors wroteComplaint #: 2575153Based on observation, interviews, record review, and review of other pertinent facility documents it was determined that the facility failed to maintain appropriate infection control practices during medication administration in accordance with in nationally accepted guidelines for infection prevention and control and the facility's policies and procedures. This deficient practice was identified for 2 of 2 residents (Resident #1 and Resident #2) reviewed for infection prevention and was evidenced by the following:1. A facility incident report dated 07/26/2025 at 6:26 P.M., was reviewed. Under, Incident Description, the document revealed the following: Nursing Description: [Resident #2] received IV Ceftin [an antibiotic] instead of the ordered Daptomycin [an antibiotic]. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to ensure that Minimum Data Sets (MDS), an assessment tool, were accurate. This deficient practice was identified for 1 of 22 residents (Resident #66) reviewed for MDS and was evidenced by the following: This is a repeat deficiency. On 07/17/2024 at 10:38 AM, the surveyor observed Resident #66 being wheeled down the hall. The resident's speech was difficult to understand, but they were loudly speaking about no respect. On 07/19/2024 at 8:49 AM, the Certified Nursing Assistant (CNA) stated that Resident #66 can be combative and yells. A review of the hybrid medical records (MR) revealed that Resident #66 was admitted with diagnoses which included but were not limited to; [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice by failing to document the use of oxygen in the Electronic Medical Record (EMR) for 1 of 2 residents (Resident #46) reviewed for respiratory care. This deficient practice was evidenced by: On 07/17/2024 at 10:30 AM during the initial tour, the surveyor observed Resident # 46 in bed. Resident # 46 was observed receiving oxygen through a nasal cannula (a tube delivering oxygen into the nose). The oxygen concentrator was set at 2 liters. On 07/18/2024 at 10:11 AM, the surveyor observed Resident # 46 in bed. Resident # 46 was observed receiving oxygen through a nasal cannula. The oxygen concentrator was set at 2 liters. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to preserve the dignity and personal preference for one (1) of 12 residents, Resident #51. The deficient practice is evidenced as follows: On 11/15/22 at 10:30 AM, the surveyor observed the November 2022 activity calendar hanging on display in the hallway of the facility which did not reflect any actitives for Veteran's Day and it did not mention it as a holiday on the calendar. On 11/16/22 at 12:00 PM, the surveyor interviewed Resident #51 who stated that he/she observed the flag at the facility was flying outside on the flag pole and was frayed so he discussed it with his family and their family donated his/her dad's flag. [...]

Inspectors wroteBased on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to ensure that an accurate Minimum Data Set (MDS), an assessment tool, was completed. This deficient practice was identified for 4 of 6 annual assessments of residents who were incorrectly coded as non-smoking (Residents #29, #62, #64, #65) and was evidenced by the following: 1. The surveyor reviewed the admission Record for Resident #29 which reflected that the resident was admitted with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness of one side of the body). The surveyor reviewed the Annual MDS tool with reference date of 06/30/2021 which identified the resident as a non-smoker. The surveyor observed the resident's name on the facilities' Safe Smoking List. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to implement a comprehensive care plan for one (1) of 20 residents (Resident #76) reviewed for the implementation of a care plan. This deficient practice was evidenced by the following: On 11/07/22 at 11:32 AM, the surveyor observed Resident #76 in his/her room. An oxygen concentrator was observed to the left side of his/her bed. The surveyor observed that Resident #76 was not utilizing the oxygen. On 11/07/22 at 01:24 PM, the surveyor observed Resident #76 in bed. The surveyor observed that Resident #76 was not utilizing the oxygen. Resident # 76 stated that he/she uses the oxygen at night. On 11/09/22 at 11:07 AM, the surveyor observed Resident #76 in a meeting. The surveyor observed that Resident #76 was not utilizing oxygen. [...]

Inspectors wroteBased on interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure that the care and documentation of a resident's dialysis access site was maintained in accordance with professional standards of practice. This was identified for Resident #52, one (1) of one (1) resident reviewed for dialysis. This deficient practice was evidenced by the following: On 11/14/22 at 11:00 AM, the surveyor went to visit Resident #52 in the room. The resident was not there, and a unit staff member informed the surveyor that the resident was at dialysis. Review of the admission Record from the electronic medical record (EMR) indicated that Resident #52 was admitted to the facility 12/2019. [...]

Inspectors wroteBased on observation, interview, and review of the medical record and other facility documentation, it was determined that the facility failed to follow physician orders related to the use of oxygen for one (1) of two (2) residents (Resident #76) reviewed for respiratory care. This deficient practice was evidenced by: This deficient practice was evidenced by the following: On 11/07/22 at 11:32 AM, the surveyor observed Resident #76 in his/her room. An oxygen concentrator was observed to the left side of his/her bed. The surveyor observed that Resident #76 was not utilizing the oxygen. On 11/07/22 at 01:24 PM, the surveyor observed Resident #76 in bed. The surveyor observed that Resident #76 was not utilizing the oxygen. Resident # 76 stated that he/she uses the oxygen at night. On 11/09/22 at 11:07 AM, the surveyor observed Resident #76 in a meeting. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure staff wore appropriate personal protection equipment (PPE) in accordance with nationally accepted guidelines for infection prevention and control upon entering a resident's room (Resident #433) that was identified as COVID-19 Persons Under Investigation (PUI). According to the U.S Centers for Disease Control and Prevention (CDC) guidelines, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 09/23/22, included resources for Recommended Infection Prevention and Control (IPC) practices, specifically the Personal Protection Equipment (PPE). [...]

Inspectors wroteBased on observations, interviews, and review of facility documentation it was determined that the facility failed to provide a clean and sanitary environment for one (1) of 20 residents reviewed (Resident #3). This deficient practice was identified by the following On 11/15/22 at 10:30 AM, the surveyor observed the floor in Resident #3's room was dirty and needed to be cleaned. There was dirt built up on the floor and woodwork. The surveyor also observed that there was no toilet paper or paper towels in the bathroom and the resident could use the bathroom independently. The bathroom floor was also dirty. Review of the Electronic Medical Record (EMR) revealed that Resident #3 had a Brief Interview of Mental Status of 03, meaning the resident had severe cognitive impairment. [...]