Complete Care at Mercerville LLC

• Star rating

  The CMS overall star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS staffing star rating changed from 4 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 3 of 5.

• Fire safety citation

  CMS removed citation K0211 from the fire safety inspection on May 2, 2025.

• Fire safety citation

  CMS removed citation K0225 from the fire safety inspection on May 2, 2025.

• Fire safety citation

  CMS removed citation K0281 from the fire safety inspection on May 2, 2025.

• Fire safety citation

  CMS removed citation K0293 from the fire safety inspection on May 2, 2025.

• Fire safety citation

  CMS removed citation K0321 from the fire safety inspection on May 2, 2025.

• Fire safety citation

  CMS removed citation K0355 from the fire safety inspection on May 2, 2025.

• Fire safety citation

  CMS removed citation K0363 from the fire safety inspection on May 2, 2025.

• Fire safety citation

  CMS removed citation K0741 from the fire safety inspection on May 2, 2025.

• Fire safety citation

  CMS removed citation K0921 from the fire safety inspection on May 2, 2025.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 2 of 5.

CMS lists this as a standard inspection.

• Citation F0809. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

  CMS lists it as corrected on June 6, 2025.

• Citation F0565. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to organize and participate in resident/family groups in the facility.

  CMS lists it as corrected on June 6, 2025.

• Citation F0637. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Assess the resident when there is a significant change in condition

  CMS lists it as corrected on June 6, 2025.

• Citation F0641. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident receives an accurate assessment.

  CMS lists it as corrected on June 6, 2025.

• Citation F0838. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

  CMS lists it as corrected on June 6, 2025.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on June 6, 2025.

  CMS has cited this home for F0880 2 times since 2022.

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CMS lists this as a complaint inspection.

• Citation F0842. Severity B: potential for minimal harm, pattern.

  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  CMS lists it as corrected on April 16, 2025.

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• Star rating

  The CMS staffing star rating changed from 4 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 5 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS overall star rating changed from 4 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS quality measures star rating changed from 5 of 5 to 4 of 5.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 4 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 2 of 5.

CMS lists this as a standard inspection and a complaint inspection.

• Citation F0698. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide safe, appropriate dialysis care/services for a resident who requires such services.

  CMS lists it as corrected on November 30, 2023.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on December 15, 2023.

  CMS has cited this home for F0812 2 times since 2022.

• Citation F0584. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  CMS lists it as corrected on November 30, 2023.

• Citation F0644. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

  CMS lists it as corrected on November 30, 2023.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on November 30, 2023.

• Citation F0677. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on November 30, 2023.

• Citation F0678. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

  CMS lists it as corrected on November 30, 2023.

• Citation F0686. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on November 30, 2023.

• Citation F0732. Severity B: potential for minimal harm, pattern.

  The rule CMS cited: Post nurse staffing information every day.

  CMS lists it as corrected on November 30, 2023.

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CMS lists this as a standard inspection.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on June 1, 2022.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on June 8, 2022.

• Citation F0888. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure staff are vaccinated for COVID-19

  CMS lists it as corrected on June 1, 2022.

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