Pennsylvania Department of Health
QUALITY LIFE SERVICES - MERCER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on June 17, 2026, at Quality Life Services - Mercer, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID #034102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 17, 2026, it was determined that Quality Life Services - Mercer was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type II (111), protected, non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100

Based on document review, observation, and interview, the facility failed to maintain portable floor plans that outlined designated rated partitions, affecting the entire facility.

Findings include:

Document review on June 17, 2026, at 1:00 p.m., revealed the facility failed to provide a set of accurate, portable floor plans. The Division of Safety Inspection is requiring that all facilities under its jurisdiction provide a portable, accurate floor plan on-site, to be used during the Life Safety Code Survey.

The Life Safety Code Floor Plan shall include the following:

a. Smoke barrier walls (outside wall to outside wall);
b. Fire barrier walls (1-2 hour walls);
c. Horizontal exits;
d. Rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) will be clearly designated. It is the facility's responsibility to have all rated rooms indicated on its Life Safety Code Floor Plan;
e. Required exits should be clearly noted;
f. Shaft walls.

Interview with the maintenance supervisor on June 17, 2026, at 1:00 p.m., confirmed the Life Safety Code Floor Plan provided during the survey failed to accurately contain the listed items.

Plan of Correction - To be completed: 07/31/2026

The facility updated the portable floor plan to clearly identify smoke barrier walls, fire barrier walls, horizontal exits, rated rooms (storage, soiled utility, and medical gas rooms), required exits, and shaft walls.

The Administrator educated the Maintenance Director on maintaining accurate and current Life Safety Code floor plans, including reviewing, updating, and ensuring a portable floor plan is available during Life Safety Code surveys.

The updated floor plan will be reviewed through the QAPI process.

NFPA 101 STANDARD Doors with Self-Closing Devices:

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.

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0223

Based on observation and interview, the facility failed to maintain doors with self-closing devices, affecting one of over five doors.

Findings include:

Observation on June 17, 2026, at 1:10 p.m., revealed the first floor east hall physical therapy room door had the self-closing device removed.

Interview with the maintenance supervisor on June 17, 2026, at 1:10 p.m., confirmed the disabled closing device.

Plan of Correction - To be completed: 07/31/2026

The facility scheduled installation of a self-closing device on the physical therapy room door located on the first-floor east hall.

After installation, the facility floor plan will be updated and identify the smoke barrier wall.

The Maintenance Director was educated on maintaining doors requiring self-closing devices.

Monthly audits of magnetic lock testing will be completed for three months to ensure compliance.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on document review and interview, the facility failed to maintain fire alarm system requirements for one of one system.

Findings include:

1. Document review on June 17, 2026, at 9:50 a.m., revealed the facility failed to provide smoke detector sensitivity testing documentation within the previous two years.

2. Document review on June 17, 2026, at 9:50 a.m., revealed the facility had not conducted a six-month battery replacement for the battery-operated smoke detectors in resident rooms.

3. Document review on June 17, 2026, at 9:50 a.m., revealed the facility failed to provide documentation for a semi-annual visual inspection of the fire alarm system.

Interview with the maintenance supervisor on June 17, 2026, at 9:50 a.m., confirmed the deficiencies.

Plan of Correction - To be completed: 07/31/2026

The facility confirmed smoke detector sensitivity testing was completed on March 3, 2026. The report was filed in Life Safety records and is readily accessible for future surveys and inspections.

The facility will ensure annual smoke detector sensitivity test is completed.

Battery-operated smoke detectors in resident rooms will have batteries replaced every six months.

The facility completed the semi-annual visual inspection of the fire alarm system.

The Maintenance Director was educated on annual smoke detector sensitivity testing, six-month battery replacement for resident room smoke detectors, and semi-annual fire alarm system inspections.

NFPA 101 STANDARD HVAC:

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on document review and interview, the facility failed to maintain heating, ventilating, and air conditioning (HVAC) equipment, affecting the entire facility.

Findings include:

Document review on June 17, 2026, at 9:30 a.m., revealed the facility failed to provide documentation that the fire/smoke dampers had been tested and exercised within the previous four years.

Interview with the maintenance supervisor on June 17, 2026, at 9:30 a.m., confirmed the documentation was not provided.

Plan of Correction - To be completed: 07/31/2026

The facility contacted the HVAC vendor to schedule the 4 year fire/smoke damper inspection and testing.

The facility will ensure the fire/smoke damper inspections and testing are completed every four years as required.

The Administrator educated the Maintenance Director on NFPA 101 requirements for inspection and testing of the fire/smoke damper system.

NFPA 101 STANDARD Fire Drills:

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, the facility failed to perform one of twelve required fire drills.

Findings include:

Document review on June 17, 2026, at 9:21 a.m., revealed the facility lacked documentation for a second quarter, third shift fire drill.

Interview with the maintenance supervisor on June 17, 2026, at 9:21 a.m., confirmed the facility lacked the fire drill documentation.

Plan of Correction - To be completed: 07/31/2026

The facility will ensure fire drills are conducted at varying, unexpected times on all three shifts each quarter.

The Administrator educated the Maintenance Director on the requirement to conduct fire drills at unexpected times.

Fire drill schedules and completion will be reviewed through the QAPI process.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, the facility failed to maintain electrical power cords in one of over fifty rooms.

Findings include:

Observation on June 17, 2026, at 1:03 p.m., revealed the DON office had a coffee pot plugged into a surge protector.

Interview with the maintenance supervisor on June 17, 2026, at 1:03 p.m., confirmed the power cord deficiency.

Plan of Correction - To be completed: 07/31/2026

The facility immediately removed the non-compliant power strip from the DON's office.

The Administrator educated the Maintenance Director and Maintenance Technician on the proper use of power strips in accordance with NFPA 101 requirements for long term care facilities.

The Maintenance Director will complete weekly audits for four weeks, followed by monthly audits for 2 months, to ensure ongoing compliance with NFPA 101 electrical equipment requirements.

Audit results will be maintained and reviewed through the QAPI process.

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