Preferred Care at Mercer: Wound Care Falsified - NJ
The dressing on Resident 3 told a different story than the paperwork. When a federal surveyor examined it on the morning of November 3, 2025, it was stamped with the date and shift from November 2's day shift. The treatment record, called a TAR, showed the wound had been dressed four times since then: November 1 day shift, November 1 evening shift, November 2 day shift, November 2 evening shift, and November 3 day shift. Five entries. All signed.
The unit manager was standing there when the surveyor pointed this out. The surveyor asked a simple question: if the dressing had actually been changed on the November 2 evening shift, or again on November 3's day shift, would it still be dated November 2 morning?
"No," the unit manager said. "It wasn't done."
Resident 3 has moderate cognitive impairment, with a score of 9 on the Brief Interview for Mental Status, a standardized cognitive screening tool. His physician had ordered wound care to his right ischial area, the bony prominence at the base of the pelvis, twice daily: calcium alginate applied after cleansing with normal saline, then covered with a foam dressing, every day shift and every evening shift. The care plan, initiated in April 2025, listed actual skin integrity as a focus area. The intervention was straightforward: administer treatment as ordered.
The treatment records said it was happening. The wound said otherwise.
What happened next is the part that matters most.
When the surveyor met with the Director of Nursing at 1:40 that afternoon, she asked what it means when a nurse signs the TAR. The DON's answer was direct: it means the care was done. Then, according to the inspection report, the Director of Nursing produced progress notes documenting that the resident had refused wound care. Those notes had not been presented before the surveyor started asking questions. They were created after.
The inspection report does not say the refusal notes were falsified. It says they were "created after the surveyor inquiry." That timing is the finding.
Nursing home records carry legal and clinical weight precisely because they are supposed to reflect what happened, not what staff wish had been documented once someone starts looking. A TAR signed by a nurse is a representation that care occurred. A progress note explaining why it didn't occur is something that should exist before an inspector pulls the dressing back and reads the date on it.
The facility's own wound care policy, last reviewed February 1, 2025, states that wound treatments will be provided in accordance with physician orders. That policy was reviewed as part of the inspection.
The violation was cited at a harm level of minimal harm or potential for actual harm. That is the lower end of the federal harm scale, but it does not mean the wound was unaffected. Ischial wounds, located where the body bears weight during sitting, are among the more difficult pressure injuries to heal. Missed treatments do not simply reset to zero. Each skipped application of calcium alginate, each shift where the wound goes uncleaned and uncovered as ordered, is a gap in the healing process.
How many shifts were actually missed is not established by the inspection report. The dressing dated November 2 morning was the only physical evidence the surveyor could examine. The TAR showed completed entries across multiple shifts. The unit manager confirmed at least some of those entries were wrong.
What the facility's records cannot now cleanly answer is how long the wound went without the care its physician ordered, and whether the progress notes produced that afternoon accurately reflect what Resident 3 said, or when.
Preferred Care at Mercer is a long-term care facility in Ewing, New Jersey. The inspection was a complaint survey, meaning someone had already raised a concern before the surveyor walked in on November 3.
Resident 3 was still there when the dressing was examined. His wound care plan had been active for more than six months.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Preferred Care At Mercer from 2025-11-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 5, 2026 · Our methodology
PREFERRED CARE AT MERCER in EWING, NJ was cited for violations during a health inspection on November 3, 2025.
The dressing on Resident 3 told a different story than the paperwork.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.