Cycle 1
Health 2025-05-02 · Fire 2025-05-02
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Hamilton Township, NJ
Complete Care At Mercerville LLC
4-star overall rating with 3-star inspections with 7 recent health deficiencies
2240 Whitehorse-Mercerville Road, Hamilton Township, NJ
(609) 586-7500
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
114
Certified beds
Average residents
102
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1970-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
85 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.53
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.45
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.19
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
3.61
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,181
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.21
Composite VBP score used to determine payment impact.
Payment multiplier
0.9826
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.97
Baseline 23.12% · Performance 20.39% · Measure score 3.97 · Achievement 2.24 · Improvement 3.97
Healthcare-associated infections
0.54
Baseline 8.62% · Performance 8.24% · Measure score 0.54 · Achievement 0 · Improvement 0.54
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
1.85
Baseline 3.41 hours · Performance 3.60 hours · Measure score 1.85 · Achievement 1.85 · Improvement 0.31
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.19% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 130 · Observed rate 13.08% · Lower 95% interval 8.38% |
| Discharge to community | 51.73% |
50.57%
1.2 pts better
|
No Different than the National Rate · Eligible stays 125 · Observed rate 40.8% · Lower 95% interval 40.14% |
| Medicare spending per beneficiary | 1.21 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 128 · Denominator 128 |
| Falls with major injury | 0.78% |
0.77%
About the same
|
Numerator 1 · Denominator 128 |
| Discharge self-care score | 80.52% |
53.69%
26.8 pts better
|
Numerator 62 · Denominator 77 |
| Discharge mobility score | 72.73% |
50.94%
21.8 pts better
|
Numerator 56 · Denominator 77 |
| Pressure ulcers or injuries, new or worsened | 4.69% |
2.29%
2.4 pts worse
|
Numerator 6 · Denominator 128 · Adjusted rate 3.71% |
| Healthcare-associated infections requiring hospitalization | 8.25% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 78 · Observed rate 11.54% · Lower 95% interval 4.98% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 103 |
| Staff flu vaccination coverage | 98.11% |
42%
56.1 pts better
|
Numerator 104 · Denominator 106 |
| Discharge function score | 81.82% |
56.45%
25.4 pts better
|
Numerator 63 · Denominator 77 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 41 · Denominator 41 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 50 · Denominator 50 |
| Resident COVID-19 vaccinations up to date | 53.73% |
25.2%
28.5 pts better
|
Numerator 36 · Denominator 67 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.6 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.1
0.7 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.0%
7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.2%
2.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
2.4%
0.6 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.4% · Q3 1.2% · Q4 2.4% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.7% |
11.4%
5.7 pts better
|
11.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 7.9% · Q3 6.2% · Q4 4.5% · 4Q avg 5.7% |
| Percentage of long-stay residents who lose too much weight | 2.0% |
4.6%
2.6 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 2.6% · Q4 2.6% · 4Q avg 2.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.6% |
19.0%
9.4 pts better
|
19.6%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 9.1% · Q3 10.1% · Q4 9.0% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.8% |
13.5%
1.7 pts better
|
16.7%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 9.7% · Q3 12.1% · Q4 11.8% · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 2.4% |
9.8%
7.4 pts better
|
16.3%
13.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 3.3% · Q3 2.7% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.1% |
9.7%
7.6 pts better
|
14.9%
12.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.9% · Q3 1.4% · Q4 1.4% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 3.4% |
15.9%
12.5 pts better
|
19.8%
16.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 6.5% · Q3 1.2% · Q4 2.3% · 4Q avg 3.4% |
| Percentage of long-stay residents with pressure ulcers | 1.7% |
6.0%
4.3 pts better
|
5.1%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
78.7%
21.1 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.3% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.0% |
8.2%
6.2 pts better
|
12.0%
10 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.0% · Observed 2.0% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.2%
0.6 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 1.1% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
80.1%
19.9 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.8% |
25.4%
2.4 pts worse
|
23.9%
3.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.8% · Observed 28.3% · Expected 24.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-16 · Fire 2023-10-16
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-05-10 · Fire 2022-05-10
5 health deficiencies
Top issue: Infection Control (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-02
F809 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-02
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-02
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-02
F838 · Administration Deficiencies
Health
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.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-06
B · Minimal harm
2025-03-11
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-04-16
E · Potential for more than minimal harm
2023-10-16
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-11-30
E · Potential for more than minimal harm
2023-10-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-10-16
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-16
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-16
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-30
B · Minimal harm
2023-10-16
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-06-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-15
D · Potential for more than minimal harm
2023-06-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-15
F · Potential for more than minimal harm
2022-05-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-06-01
D · Potential for more than minimal harm
2022-05-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-08
D · Potential for more than minimal harm
2022-05-10
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-06-01
Penalties and ownership
What sits behind the stars
Ownership
Pc Nj1 Opcos LLC
5% Or Greater Direct Ownership Interest · Organization
Grewal, Baljinder
Operational/Managerial Control · Individual
Levovitz, Yitz
Operational/Managerial Control · Individual
Mercado, Wanda
Operational/Managerial Control · Individual
Pc Wta Opco Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Peace Capital Holdings LLC (De)
5% Or Greater Indirect Ownership Interest · Organization
Sheikh, Selim
Operational/Managerial Control · Individual
Sms 2021 Trust
5% Or Greater Indirect Ownership Interest · Organization
Stein, Shalom
Corporate Officer · Individual
Welltower Inc
5% Or Greater Security Interest · Organization
Winkler, Mordechal
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Spring Hills Post Acute Hamilton
Hamilton, NJ
3-star overall rating with 2-star inspections with $17,192 in total fines with 12 recent health deficiencies
#2
Hamilton Grove Healthcare And Rehabilitation, LLC
Hamilton, NJ
1-star overall rating with 2-star inspections with abuse icon flag with $54,275 in total fines with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Preferred Care At Hamilton
Hamilton Square, NJ
4-star overall rating with 3-star inspections with $48,825 in total fines with 11 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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