Pennsylvania Department of Health
QUALITY LIFE SERVICES - MERCER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

QUALITY LIFE SERVICES - MERCER
Inspection Results For:

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QUALITY LIFE SERVICES - MERCER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey completed on June 18, 2026, it was determined that Quality Life Services-Mercer, was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Observations:

Based on review of clinical records and staff interviews, it was determined the facility failed to provide personal care in accordance with the comprehensive person-centered care plan for one of 16 residents reviewed (Resident R7).

Findings include:

Review of a current facility policy entitled "Activities of Daily Living" revealed that residents will be provided "equipment and instruction for mouth care, shaving, make-up and hair care."

Resident R7's clinical record revealed an admission date of 8/25/26, with diagnoses that included memory deficit, arthritis and right sided weakness. Resident R7 was identified with cognitive impairment.

Resident R7's Care Plan dated 5/25/26, revealed will "will have all my physical, medical and psychological needs met during the duration of my stay in this home."

Observation on 6/17/26, at approximately 1:40 p.m. revealed Resident R7 to not be shaven and had long fingernails with dirt underneath the nails.

During an interview on 6/17/2026, at 2:40 p.m. the Director of Nursing confirmed that Resident R7 had not been shaven and had long fingernails with dirt under them.

28 Pa Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 07/16/2026

Identified Resident R7 was immediately provided with grooming services, including shaving and nail care.

The Director of Nursing an audit on all Residents requiring staff assistance with grooming and personal hygiene. Any identified concerns were addressed immediately.

The Director of Nursing provided education on the facility's policy for activities of daily living to nurses and nurse's aides. Education emphasized the importance of providing routine grooming and hygiene services, including shaving and nail care.

Director of Nursing/Designee will conduct weekly audits of five Residents requiring assistance with grooming and personal hygiene three times a week for four weeks. Completed audits will be reviewed at the next Quality Assurance and Performance Improvement (QAPI) meeting to determine if audits need to continue to meet compliance. Compliance date is July 16, 2026.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

Based on review of a facility policy, observations and staff interviews, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in one of two refrigerators on the nursing unit (resident refrigerator utilized for food brought in from the community).

Findings include:

A facility policy entitled "Food Brought in From Outside Sources" dated 1/26, revealed the purpose of this policy is to ensure the nursing homes have procedures in place for the safe and sanitary storage, handling and consumption of food including food and fluids purchased through third party vendors and brought in by family members and other visitors.

Observation on 6/15/26, at 1:20 p.m. revealed a refrigerator with freezer in the residents' dining room with six individual ice packs for resident care stored amongst resident food items in the freezer.

Interviews at the time of the observation with the Dietary Manager and Dietitian confirmed that the ice packs for resident care stored along with the residents' food were unsanitary and are not permitted to be stored with the residents' food.

Interview with the Nursing Home Administrator (NHA) on 6/15/26, at 3:10 p.m. confirmed that resident care items, such as ice packs, are not permitted to be stored with resident food to ensure all food items have safe and sanitary storage.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1)(3) Management

Plan of Correction - To be completed: 07/16/2026

On June 17, 2026, the ice packs were immediately removed from resident refrigerator located in the dining room. Resident Refrigerator #1 and the nourishment mini-refrigerator #2, located behind the nurses' station, were inspected to verify that no resident care items were stored with resident food. No additional resident care items were identified in either refrigerator.

Nursing Home Administrator, Director of Nursing and Dietary Manager reviewed the facility's policy on "Food Brought in from outside sources" with all nursing and dietary staff. Education was provided on proper food storage practices.

Director of Nursing/designee will conduct audits of all resident food refrigerators and freezers three times per week for four weeks to ensure that only resident food items are stored in resident food storage areas.

Completed audits will be reviewed at the next Quality Assurance Performance Improvements (QAPI) meeting for compliance to determine if audits need to continue. Compliance date is July 16, 2026.

35 P. S. § 448.809b LICENSURE Photo Id Reg:

Law amended July 11, 2022 Act 79 2022 HB 2604

(1) The photo identification tag shall include a recent
photograph of the employee, the employee's first name, the
employee's title and the name of [the health care facility or
employment agency.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.

(2) The title of the employee shall be as large as possible
in block type and shall occupy a one-half inch tall strip as
close as practicable to the bottom edge of the badge.

(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title "Physician."
(ii) A Doctor of Osteopathy shall have the title
"Physician."
(iii) A Registered Nurse shall have the title
"Registered Nurse."
(iv) A Licensed Practical Nurse shall have the title
"Licensed Practical Nurse."
(v) All other titles shall be determined by the
department. Abbreviated titles may be used when the title
indicates licensure or certification by a Commonwealth
agency.

(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.

Observations:

Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to ensure that all employees were wearing photo identification (ID) tags that included all the required information for three of six employees observed (Dietary Employees E1, E2, and E3).

Findings include:

A facility policy entitled "Employee Name Badge Policy" dated January 2026, revealed all employees, contractors, and agency personnel are required to wear an official facility-issued name badge at all times while on duty or representing the organization. Name badges serve to identify staff to residents, families, visitors, and regulatory personnel and must reflect a professional and uniform appearance.

Observations on 6/15/26, between 10:30 a.m. and 1:45 p.m. revealed Dietary Employees' E1, E2, and E3 lacked a photo or other visual identification for staff, residents, and visitors to know what position he/she was in the facility.

Interview with the Dietary Manager on 6/15/26, at 1:45 p.m. confirmed three of the six employees working in the dietary area were observed without an ID name tag/badge. The Dietary Manager further confirmed that Human Resources was responsible for preparing the employee's ID name tag/badge, and each employee is then required to wear the ID name tag/badge during their work shift.

Plan of Correction - To be completed: 07/16/2026

Three dietary employees were immediately removed from resident care areas until facility issued photo identification badges containing the required photograph, employee first name, title, and facility name were issued. Education was provided an educational write up for non-compliance with wearing the facility badge for identification. The employees resumed duties after compliance was verified on June 17, 2026.

The Nursing Home Administrator completed an initial audit of all current employees to verify that each employee had a facility identification badge. Any employee found without a badge was immediately issued a replacement prior to the implementation of ongoing badge compliance audits.

Nursing Home Administrator and Human Resources re-educated all Department Heads on the facility's employee identification badge policy to reinforce compliance with state regulations and facility expectations. Human Resources issues facility identification badges to all new employees during new hire orientation. Lost or damaged badges must be reported immediately to Human Resources, as HR is the only department authorized to request new or modified badges.

The Nursing Home Administrator or designee will conduct employee identification badge compliance audits three times per week for four weeks. Each audit will include five employees from the day shift, five employees from the afternoon shift, and three employees from the night shift to verify that employees are wearing their required facility-issued identification badges. Any employee found to be out of compliance will receive immediate education, an educational write-up, and progressive disciplinary action in accordance with the facility's disciplinary policy.

Audit results will be reviewed through the facility's Quality Assurance and Performance Improvement (QAPI) process to determine if audits need to continue to meet compliance. Compliance date July 16, 2026.

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