Preferred Care at Mercer

In the surveyor’s words

From the most serious findings on record at Preferred Care at Mercer, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF755Jan 15, 2026

  Based 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.Findings include:During observation of medication cart one on the [NAME] Hall on 01/13/26 at 1:00 PM, Licensed Practical Nurse (LPN) 2 revealed routine and controlled medications blister pack labels and controlled substance inventory log sheets located in medication cart one,… […]

• No harm, potential for more than minimal, widespreadF812Jan 15, 2026

  Based 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. Findings include:1.During the initial kitchen tour and observation on 01/12/26 at 9:58 AM, the dishwasher revealed the tile wall and floor behind and underneath the dishwasher, covered in dark blackish-brown debris consisting of grease, food debris and dust and dirt. […]

• No harm, potential for more than minimal, patternF686Nov 3, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF759Aug 1, 2025

  Complaint #: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. […]

• No harm, potential for more than minimal, patternF550Nov 17, 2022

  Based 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. […]