Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Preferred Care At Mercer during CMS and state inspections, most recent first.
Medication cart observations found routine and controlled medication blister packs and CS inventory sheets labeled with “See MD Orders” instead of specific directions for use on four carts. An LPN, RN, unit manager, DON, and pharmacy consultant described the facility’s process for relying on the MAR or EMR for administration instructions, while the facility policy required medications to be appropriately and safely labeled with directions for use.
Kitchen sanitation and ice machine maintenance were deficient when surveyors observed heavy grease, food debris, dust, and dirt on the floor, walls, and fixed equipment behind and beneath the dishwasher, steam table, range, ovens, and prep surfaces. Surveyors also found slimy brown and blackish-brown bio-growth on two ice machine chutes, while the DM and MD stated the areas were supposed to be cleaned routinely and maintenance was responsible for the ice machines.
Failure to timely document Medicare noncoverage notices for two residents. One resident had Alzheimer’s disease and severely impaired cognition, and the SNF beneficiary form showed an ABN with initials on the signature line, but the chart had no nursing note documenting a discussion about appeal rights or noncoverage. Another resident with muscle wasting and atrophy had an ABN marked refused to sign, but there was no EMR documentation of a discussion with the RP or resident about the NOMNOC, and the SSD stated these conversations were not documented in the EMR.
A resident admitted with major depressive disorder, anxiety disorder, and chronic PTSD had an MDS showing intact cognition and a CAA that triggered an actual need related to PTSD, but the EMR care plan had no interventions addressing the PTSD diagnosis. The DON acknowledged a care plan should have been created, and facility policy required a comprehensive person-centered care plan with measurable objectives and timeframes for identified medical, nursing, and psychosocial needs.
A resident assessed as high risk for smoking and requiring an apron was observed smoking without one. The AD said nursing verbally informed him/her when residents needed an apron, but the resident's smoking assessment was not reviewed by the AD and the resident was treated as a safe smoker. The Subacute Unit Manager and DON both confirmed the assessment indicated the resident should have been wearing an apron while smoking.
Failure to Explore Alternatives Before Side Rail Use: A resident admitted with a brain disorder had side rails ordered and present on both sides of the bed, but the nursing admission assessment did not document that alternatives were explored before side rail use. The Subacute Unit Manager said the alternative-exploration process had not been completed, while the DON stated side rails were on all beds and staff did not look at alternatives because the rails were not used as restraints.
The facility failed to provide wound care treatments as ordered by physicians for three residents with skin impairments. In each case, the treatment administration record was signed as if wound care was completed, but direct observation and record review showed that dressings were not changed as required. The DON confirmed that signing the TAR should indicate completion of care, but this was not consistently done.
A nurse administered the wrong IV antibiotic to a resident with multiple infections, including MRSA bacteremia, by failing to verify the medication before administration. The nurse brought two IV medications into the room, intended for different patients, and gave Ceftin instead of the prescribed Daptomycin. The error was discovered within minutes, and staff interviews confirmed that facility policy and the five rights of medication administration were not followed.
Surveyors found that the facility did not have an infection prevention and control program in place, indicating a lack of systematic measures to address infection risks for residents and staff.
A facility failed to ensure accurate MDS assessments for a resident with schizoaffective disorder, leading to repeated inaccuracies in the psychiatric/mood disorder section. The resident was incorrectly documented as having schizophrenia instead of schizoaffective disorder across multiple assessments. The DON acknowledged the discrepancies, noting the responsibility of the MDS coordinator to ensure accurate assessments.
A resident with heart failure and a physician's order for oxygen was observed receiving oxygen, but the use was not documented in the EMR as required. Interviews with staff confirmed the lack of documentation, which is against the facility's policy on oxygen administration.
Medication Labels Did Not Include Directions for Use
Penalty
Summary
The facility failed to implement pharmacy processes for labeling medications, including controlled substances, on four medication carts observed for medication storage and labeling of 27 sampled residents. During observation of Medication Cart One on the [NAME] Unit and Medication Cart Two on the same unit, as well as Medication Cart One and Medication Cart Two on the Ewing Unit, routine and controlled medication blister pack labels and controlled substance inventory log sheets were found to reflect “See MD Orders” as the medication administration directions for use. During interviews, an LPN and an RN stated that nurses were responsible for ensuring the resident’s name, prescribing doctor, directions for medication administration, prescription number, issuing pharmacy name, and prescription issue date were reflected on the blister pack label and narcotic inventory sheet. The RN stated that using “See MD Orders” as the instruction did not follow the medication rights for verification against the MAR before administration. The Sub-Acute Unit Manager stated that “See MD Orders” was a facility process used to prevent the need for clarification or questioning of orders, and that physician orders were written in the hard chart and then entered into the EMR. The DON stated that nurses and unit managers were responsible for ensuring medication rights were followed and that the medication label and MAR matched. The certified pharmacy consultant stated that medication cart audits were conducted to check for regulatory compliance, including proper labeling aligned with the MARs/orders, and said that New Jersey pharmacies were not required to write out the instructions for use on the drug card label and that “See MD Orders” was appropriate. Review of the facility policy titled LTC Pharmacy Services stated that medications dispensed to residents are to be appropriately and safely labeled and that labels shall include directions for use.
Kitchen and Ice Machine Sanitation Deficiencies
Penalty
Summary
The facility failed to prevent the build-up of grease, food crumbs, dirt, and debris on fixed kitchen equipment and surrounding surfaces in one kitchen area. During the initial kitchen tour, the tile wall and floor behind and underneath the dishwasher were covered in dark blackish-brown debris made up of grease, food debris, dust, and dirt, and the same debris was observed on the undercarriage of the heating unit, the legs of the steam table, food preparation tables, shelves, and on the outside of the gas range and double ovens. The Dietary Manager stated the areas were tried to be cleaned daily, but during later observations the range, double ovens, steam table, and preparation surfaces behind and beneath the equipment remained soiled. The Dietary Manager later stated a pressure washer had been used but had not been successful, and also stated the area behind and underneath the dishwasher had been thoroughly cleaned and was free of debris. The facility also failed to clean and maintain two ice machines. One ice machine had a slimy, brownish substance on the inside and outside of the chute, and the other had the same brownish substance on the chute along with slimy blackish-brown and white bio-growth on the metal areas of the chute assembly. The maintenance logs showed quarterly cleaning activities for coils, motors, and filters, and the Maintenance Director stated maintenance was responsible for wiping down the machines daily and taking them apart every 90 days to clean internal parts. The facility policy required clean and sanitary kitchen facilities and stated that food preparation areas, food-contact surfaces, dining facilities, and equipment were to be cleaned and sanitized after each use.
Failure to Timely Document Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to ensure timely Notice of Medicare Non-Coverage notification was provided for two residents reviewed for beneficiary notification. For one resident, the record showed admission with Alzheimer’s disease and a quarterly MDS with a BIMS score of 5 out of 15, indicating severely impaired cognition. The SNF Beneficiary Notification Review form showed Medicare Part A skilled services started on 08/23/25 and the last covered day was 10/15/25, with an ABN dated 10/10/25 and initials on the signature line. However, the nurse’s notes for October and November 2025 contained no documentation of a discussion with the resident about the Medicare noncoverage notice. For the second resident, the record showed admission with diagnoses including muscle wasting and atrophy and a quarterly MDS with a BIMS score of 15 out of 15. The SNF Beneficiary Notification Review form showed Medicare Part A skilled services started on 09/23/25 and the last covered day was 11/04/24, with an ABN dated 10/31/25 stating refused to sign. The nurse’s notes for October and November 2025 contained no documentation of a discussion with the resident’s RP about Medicare noncoverage, and no note documenting a discussion with the resident or the refusal to sign. During interviews, the SSD stated he/she spoke with residents and families about benefits ending and appeal rights but did not document those conversations in the EMR, and stated the resident with a BIMS below 10 would not be appropriate to sign the forms.
No Care Plan for PTSD Diagnosis
Penalty
Summary
The facility failed to develop a care plan for one of two residents reviewed for behavioral-emotional status, Resident 11. Record review showed Resident 11 was admitted and readmitted with major depressive disorder, anxiety disorder, and chronic PTSD. The quarterly MDS with an ARD of 12/14/25 showed a BIMS score of 14 out of 15, indicating intact cognition, and also identified PTSD as a diagnosis. The CAA worksheet dated 09/11/25 showed the mood interview triggered an actual problem/need related to PTSD. Review of the care plan in the EMR showed there were no care plans addressing Resident 11's PTSD diagnosis. During an interview on 11/21/25 at 1:05 PM, the DON stated a care plan should have been created for the resident's PTSD diagnosis and acknowledged the diagnosis was listed on the comprehensive assessment and face sheet. Facility policy titled Comprehensive Care Plans, dated 08/25, stated the facility is to develop and implement a comprehensive person-centered care plan for each resident with measurable objectives and timeframes to meet identified medical, nursing, and psychosocial needs.
Resident Smoked Without Required Apron
Penalty
Summary
The facility failed to ensure that a resident assessed as requiring an apron while smoking was provided one. Resident 105 was admitted with a diagnosis of unspecified disorders of the brain, and the admission smoking assessment dated 01/12/26 identified the resident as high risk for smoking and requiring an apron while smoking. The care plan also addressed nicotine addiction and stated the resident required supervision while smoking. During observations on 01/14/26 at 10:00 AM and 2:00 PM, Resident 105 was seen smoking without an apron. The Activities Director stated residents who wanted to smoke were assessed on admission or when they told staff they wished to smoke, and that nursing completed the assessment and verbally informed him/her when an apron was required. The Activities Director said he/she did not review Resident 105's assessment and had been told the resident was a safe smoker. The Subacute Unit Manager reviewed the smoking assessment and agreed it showed the resident was a high-risk smoker who required an apron. The DON stated the assessment should have been followed and that the interdisciplinary team should have reviewed it, and also stated the wrong button had been clicked on the assessment but it was not reviewed.
Failure to Explore Alternatives Before Side Rail Use
Penalty
Summary
The facility failed to ensure alternative measures were explored before side rails were installed for one resident, R105, who was admitted with a diagnosis of unspecified disorders of the brain. The resident’s EMR showed an admission MDS assessment still in progress, and the care plan dated 01/10/26 included 1/4 side rail use. A physician order dated 09/08/25 directed 1/2 side rails per resident request to promote a sense of security and assist with transfers and bed mobility. However, the nursing admission assessment dated 01/10/26 did not document that alternatives were explored prior to bed rail or side rail use. During observations on 01/12/25 and 01/13/25, side rails were present on both sides of R105’s bed. In interviews, the Subacute Unit Manager stated staff would assess repositioning and mobility on admission but said the process for exploring alternatives had not been completed and was unsure whether it was part of the current process. The DON stated side rails were on all beds, that consent was obtained, and that staff did not look at alternatives because the rails were not used as restraints. The facility policy titled Proper Use of Side Rails, revised 11/25, stated the purpose was to ensure safe use of side rails as resident mobility aides and to prohibit their use as restraints.
Failure to Provide Physician-Ordered Wound Care Treatments
Penalty
Summary
The facility failed to provide necessary wound care treatments as ordered by physicians for three residents with documented skin impairments. For one resident with dementia and chronic kidney disease, physician orders required Medihoney and calcium alginate dressings to be applied every eight hours. However, the treatment administration record (TAR) was signed as completed for several shifts, but direct observation revealed the dressing had not been changed as indicated, with the dressing still dated from a previous shift. The unit manager confirmed the discrepancy between the TAR and the actual dressing date. Another resident with diabetes and a diabetic foot ulcer had physician orders for specific wound care, but the TAR was left blank on two occasions, indicating the treatment was not provided. A third resident with multiple sclerosis and impaired mobility had orders for calcium alginate dressings to be changed twice daily, but observation and TAR review showed the dressing was not changed as required, despite the TAR being signed. The director of nursing confirmed that signing the TAR should indicate the treatment was completed. Facility policy required wound treatments to be provided per physician orders, but this was not followed for these residents.
Medication Error: Incorrect IV Antibiotic Administered
Penalty
Summary
A deficiency occurred when a nurse administered the incorrect intravenous (IV) antibiotic medication to a resident who had been admitted with multiple serious infections, including a peritoneal abscess, sepsis, bacteremia, and pneumonia. The resident, who had intact cognition, was prescribed Daptomycin for IV therapy following a recent hospital stay for MRSA bacteremia. On the day of the incident, the nurse brought two IV medication bags into the resident's room—one intended for the resident and another for a different patient. The nurse verified the resident's identity but failed to verify the medication itself, resulting in the administration of Ceftin, which was not ordered for the resident, instead of the prescribed Daptomycin. The error was identified by the nurse within minutes, and the infusion was stopped shortly after it began. Review of the resident's orders confirmed that only Daptomycin was prescribed, with no order for Ceftin. Interviews with facility staff, including the nurse involved, the unit manager, and the director of nursing, confirmed that the facility's medication administration policy and the five rights of medication administration were not followed in this instance. The facility's policy requires verification of the medication against the electronic medication administration record (EMAR) prior to administration, which was not completed as required.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was observed and documented by surveyors, indicating a lack of systematic measures to address infection risks within the facility. No specific residents, staff, or incidents were detailed in the report, and there were no direct observations of infection transmission or related outcomes included in the findings.
Inaccurate MDS Assessment for Resident with Schizoaffective Disorder
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Sets (MDS) for a resident, leading to a deficiency. The surveyor observed that the resident, who had a history of schizoaffective disorder, bipolar type, anoxic brain damage, and epilepsy, was inaccurately assessed in the MDS. The inaccuracies were found in the psychiatric/mood disorder section of the MDS, where the resident was incorrectly documented as having schizophrenia instead of schizoaffective disorder. This discrepancy was noted across multiple MDS assessments over a period of time. The Director of Nursing (DON) acknowledged the discrepancies and stated that the MDS coordinator was responsible for reviewing hospital records, nursing notes, diagnoses, and behaviors to ensure accurate assessments. However, the MDS nurse responsible for these assessments was no longer employed at the facility at the time of the survey. The facility's policy required the MDS coordinator to maintain current assessment data, but the inaccuracies in the resident's MDS indicated a failure to adhere to this policy.
Failure to Document Oxygen Use for Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident by not documenting the use of oxygen in the Electronic Medical Record (EMR) for a resident who required such care. The resident, who was admitted with diagnoses including palliative care and heart failure, had a physician's order to receive oxygen at two liters per minute via nasal cannula as needed for shortness of breath. Despite observations on two separate occasions where the resident was receiving oxygen, there was no documentation of this in the Treatment Administration Record (TAR). Interviews with facility staff, including an LPN and the Director of Nursing (DON), confirmed that the oxygen use was not documented as required. The facility's policy on PRN medications and oxygen administration mandates documentation of the initiation and use of oxygen, including the time, flow, indication, and method, in the TAR or progress notes. However, this documentation was missing, leading to the deficiency noted by the surveyor.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ewing
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Greenwood House Home For The Jewish Aged | 0.1 mi | ★★★★★ | 12 | 0 |
| Belle Care Nursing And Rehabilitation Center | 2.6 mi | ★★★★★ | 18 | 0 |
| Avant Rehabilitation And Care Center | 3.2 mi | ★★★★★ | 14 | 0 |
| Lawrence Rehab & Hcc/the Meadows At Lawrence | 3.8 mi | ★★★★★ | 13 | 1 |
| Lawrence Rehabilitation Hospital | 3.9 mi | ★★★★★ | 30 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.