Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Notice
Deficiencies: 0
Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 7
Aug 6, 2024
Visit Reason
A complaint investigation and recertification survey were conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, triggered by multiple complaints.
Findings
The facility was found not in substantial compliance with federal requirements based on deficiencies in accuracy of Minimum Data Set (MDS) assessments, respiratory care documentation, and life safety code violations including egress door locking, smoke detection, sprinkler system maintenance, corridor door functionality, and fire door inspections.
Complaint Details
The visit was complaint-related with multiple complaint numbers cited: NJ 160220, NJ 162387, NJ 163020, NJ 167083, NJ 171699, and NJ 172959. The facility was found not in substantial compliance based on this complaint visit.
Severity Breakdown
SS=D: 2
SS=F: 5
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure accuracy of Minimum Data Sets (MDS) assessments, specifically coding errors related to diagnosis of Schizoaffective Disorder for resident #66. | SS=D |
| Failure to document use of PRN oxygen in the Electronic Medical Record for resident #46, inconsistent with professional standards. | SS=D |
| Egress doors had locking devices that could restrict emergency exit, including a hook-type deadbolt on glass sliding doors and keyed lock on exit door by administrator's office. | SS=F |
| Smoke detection system missing in dining area open to corridor. | SS=F |
| Automatic sprinkler system deficiencies including corrosion on sprinkler heads, ceiling penetrations, and gaps around sprinkler pipes. | SS=F |
| Corridor doors not properly latching or resisting passage of smoke, including resident room doors and emergency electrical room door. | SS=F |
| Failure to inspect, test, and document fire door assemblies annually by qualified personnel. | SS=F |
Report Facts
Census: 81
Sample Size: 22
Deficiency Count: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Provided re-education to nurses regarding PRN oxygen documentation and MDS coding accuracy. | |
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding failure to document PRN oxygen administration. | |
| Regional MDS nurse | Corrected and resubmitted inaccurate MDS assessments; provided in-service education on MDS accuracy. | |
| Facility Administrator | Responsible for re-inservicing staff on exit door accessibility, smoke detector requirements, sprinkler system maintenance, corridor door compliance, and fire door inspections; oversees audits and corrective actions. | |
| Maintenance Director | Conducts inspections and maintenance related to fire safety systems including sprinkler heads and fire door assemblies. |
Document
Deficiencies: 0
Nov 17, 2022
Visit Reason
This document does not contain any visit or inspection reason.
Findings
No inspection findings or content are present in this document.
Inspection Report
Life Safety
Deficiencies: 3
Nov 4, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 11/04/2022 to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code for Preferred Care at Mercer.
Findings
The facility was found noncompliant with fire safety requirements including failure to ensure fire-rated doors to hazardous areas were self-closing and properly separated by smoke-resisting partitions, one electrical outlet near a water source lacking proper GFCI protection, and the emergency generator lacking a remote manual stop station.
Severity Breakdown
SS=E: 1
SS=D: 1
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Fire-rated doors to hazardous areas were not self-closing and not properly separated by smoke-resisting partitions as required by NFPA 101. | SS=E |
| One of eleven electrical outlets near a water source lacked proper working Ground-Fault Circuit Interrupter (GFCI) protection. | SS=D |
| The emergency generator did not have a remote manual stop station installed as required by NFPA 110. | SS=F |
Report Facts
Number of electrical outlets inspected: 11
Number of boxes stored in combustible storage room: 60
Resident sleeping rooms on upper level: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Present during inspection and confirmed findings | |
| Facility Administrator | Informed of deficiencies at exit conference and responsible for corrective actions | |
| Facility Maintenance Director | Performed repairs and testing related to deficiencies |
Inspection Report
Routine
Census: 84
Deficiencies: 0
Jan 18, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 8
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 0
Oct 29, 2021
Visit Reason
The inspection visit was conducted in response to complaint #NJ 147110 to assess compliance with regulatory requirements.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint # NJ 147110 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 0
Jun 3, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ144804, NJ141628, and NJ139440.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Complaint Details
Complaint numbers NJ144804, NJ141628, and NJ139440 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample size: 6
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 0
Mar 3, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on complaint # NJ 141316.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint # NJ 141316; the facility was found in substantial compliance.
Report Facts
Sample size: 3
Inspection Report
Routine
Census: 81
Deficiencies: 0
Jan 27, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
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