Inspection Reports for Complete Care at Mercerville

The complaint investigation was substantiated based on findings that the facility failed to properly address grievances, complete required assessments, provide adequate nutrition, maintain updated facility assessments, and follow infection control protocols.

The facility failed to consistently address resident grievances, complete significant change assessments timely, accurately complete Minimum Data Set assessments, provide and document evening snacks, review and update the facility-wide assessment annually, and ensure proper infection control practices including PPE use for residents on contact precautions.

Deficiencies were cited related to resident/family group participation, comprehensive assessment after significant change, accuracy of assessments, frequency of meals and snacks at bedtime, facility assessment, infection prevention and control, mandatory access to care staffing ratios, life safety code violations including means of egress, stairways and smokeproof enclosures, illumination of means of egress, portable fire extinguishers, corridor doors, smoking regulations, and electrical equipment testing and maintenance.

The facility failed to update Resident #2's Comprehensive Care Plan to reflect a fall that occurred on 04/30/24 and did not document interventions to address the fall, despite the resident being identified as high risk for falls.

Complaint #NJ00176679 was investigated with survey dates 02/27/2025 and 03/11/2025. The facility was found not in substantial compliance with requirements based on this complaint visit.

The facility was found not in substantial compliance with requirements related to resident records confidentiality and medical record maintenance, as well as inadequate staffing levels of Certified Nursing Assistants (CNAs) during the 14-day review period. Deficiencies were identified that could potentially affect all residents.

Complaint #: NJ00170862, NJ00172003. The facility was found deficient in CNA staffing on multiple shifts during the periods 02/25/2024 to 03/09/2024 and 09/15/2024 to 09/28/2024, affecting all residents due to short staffing as required by NJ DOH.

The facility was found not in compliance with New Jersey Administrative Code 8:39 standards for licensure of Long Term Care Facilities due to failure to meet required minimum staff-to-resident ratios for Certified Nursing Assistants (CNAs) on multiple day and overnight shifts. The facility was deficient in CNA staffing on 16 day shifts and 1 overnight shift during the review period.

Complaint #: NJ172275. The facility failed to ensure staffing ratios were met for 14 of 14 day shifts reviewed, potentially affecting all residents. The complaint was substantiated with detailed findings of CNA shortages on specific dates in April 2024.

The facility was found to be out of compliance with New Jersey staffing requirements, failing to meet the minimum Certified Nursing Assistant (CNA) staffing ratios on 14 of 14 day shifts reviewed, potentially affecting all residents.

Complaint NJ #159452 and #161368 related to cleanliness, PASRR assessment, wound care, grooming, code status, dialysis care, nurse staffing posting, and food service hygiene.

The facility was found deficient in maintaining a clean and homelike environment, failing to conduct a new PASRR Level I assessment after a new mental illness diagnosis, failing to obtain physician orders and reapply wound vac treatment, inadequate grooming care for a dependent resident, failure to honor a resident's DNR preference, improper air mattress settings for pressure ulcer prevention, inconsistent documentation and communication for dialysis care, incomplete nurse staffing postings, and inadequate infection control and equipment maintenance in the kitchen.

Deficiencies were cited related to maintaining a safe, clean, comfortable environment, PASARR coordination, professional standards of care, pressure ulcer prevention, dialysis documentation, nurse staffing, food safety, and life safety code compliance.

Complaint NJ #159452 regarding failure to maintain a clean, comfortable, homelike environment, specifically cleanliness of tube feeding pump and pole and general room cleanliness.

The facility was found to have multiple cleanliness deficiencies including black scuff marks on floors, dirty heating and air conditioner units, unlined and filled garbage cans, damaged and dirty overbed tables, and dirty tube feeding pumps and IV poles. These issues were observed in multiple resident rooms and nursing units. Interviews with staff confirmed lapses in cleaning responsibilities and protocols.

Complaint NJ00163579 regarding wound care and infection control practices was substantiated with findings of deficient practices in wound dressing documentation, medication handling, and infection prevention.

The facility failed to remove medicated gel from a resident's room after wound care, failed to sign and date wound dressings for two residents, and did not implement proper infection control techniques including failure to wear isolation gowns, change gloves appropriately, sanitize surfaces, and follow enhanced barrier precautions during wound care.

Complaint #NJ00163579 was investigated. The facility was found not in substantial compliance with professional standards of care and infection control requirements. The complaint was substantiated based on observations, interviews, and documentation review.

The facility was found not in substantial compliance with professional standards of care, specifically regarding medication administration and infection control practices. Deficiencies included failure to properly manage and document medication administration and inadequate infection prevention and control measures.

The facility was found deficient in maintaining proper kitchen sanitation practices, including unclean ovens, contaminated equipment, improper dishwashing procedures, and inadequate staff attire. Additionally, the facility failed to consistently implement COVID-19 transmission-based precautions for residents and did not ensure unvaccinated staff adhered to required PPE protocols.

The facility was found deficient in maintaining the required minimum CNA staffing ratios for 13 of 14 day shifts during the weeks of 04/03/22 to 04/16/22, with staffing levels consistently below the mandated one CNA per eight residents ratio. The facility submitted a plan of correction including audits, recruitment efforts, and monitoring to address the staffing deficiencies.

The facility was found to be noncompliant with several life safety code requirements including failure to conduct annual fire door inspections, inadequate corridor widths in non-resident areas, lack of tamper alarms on sprinkler system valves, missing smoke dampers on vents, absence of a remote manual stop station for the emergency generator, and improper storage of oxygen cylinders.

Complaint # NJ 147076 was substantiated based on findings that the facility failed to provide necessary treatment and documentation for pressure ulcers on Resident #3.

The facility was found not in substantial compliance due to failure to provide treatment and follow facility policy for pressure ulcer care for Resident #3. Documentation and physician orders for wound treatment were incomplete or missing, and treatment administration was not properly recorded.