Inspection Reports for Mercer Hill at Doylestown
2010 S Easton Rd, Doylestown, PA 18901, United States, PA, 18901
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Monitoring
Census: 76
Capacity: 97
Deficiencies: 11
Jun 30, 2025
Visit Reason
The visit was an unannounced partial inspection conducted for monitoring purposes to review the facility's compliance with regulatory requirements and the implementation of a submitted plan of correction.
Findings
The inspection identified multiple deficiencies related to resident record confidentiality, contract signatures, medical evaluations, medication management, preadmission screening, and admission support plans. The facility submitted plans of correction for all deficiencies, which were reviewed and found to be implemented or in progress with ongoing monitoring and audits.
Deficiencies (11)
| Description |
|---|
| Medication cart observed with unattended trash bag containing pill packages showing resident names and medication names, violating resident record confidentiality. |
| Resident-home contract was not signed by the resident. |
| Resident's initial medical evaluation did not include the ability to self-administer medications. |
| Resident's status change medical evaluation indicated 'none' for special health or dietary needs despite admission to secured dementia care unit. |
| Discontinued medication found in the home's medication cart. |
| Medication administration records showed medications administered but not signed out on controlled inventory sheets. |
| Resident's prescribed medication dose was not administered at the prescribed time. |
| Resident preadmission screening form did not include determination that resident's needs can be met by the home. |
| Resident's written cognitive preadmission screening was not completed within 72 hours prior to admission to secured dementia care unit. |
| Resident's initial support plan was not completed within 72 hours of admission to secured dementia care unit. |
| Controlled inventory sheets showed write overs and improper documentation of medication counts. |
Report Facts
License Capacity: 97
Residents Served: 76
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 22
Hospice Current Residents: 3
Residents Age 60 or Older: 76
Residents with Mobility Need: 22
Total Daily Staff: 98
Waking Staff: 74
Inspection Report
Monitoring
Census: 77
Capacity: 97
Deficiencies: 2
May 8, 2025
Visit Reason
The visit was a partial, unannounced monitoring inspection conducted to review the facility's compliance with regulations and the status of the submitted plan of correction.
Findings
The inspection found deficiencies related to medication storage and administration, including expired eye drops and missed medication doses. The facility submitted a plan of correction which was accepted and fully implemented by the inspection date.
Deficiencies (2)
| Description |
|---|
| Prescription medications were not stored according to manufacturer’s instructions; opened eye drops were not discarded after 28 days as required. |
| Resident medications were not administered as prescribed, including missed doses for cognitive impairment and dry mouth treatments. |
Report Facts
License Capacity: 97
Residents Served: 77
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 19
Hospice Current Residents: 3
Total Daily Staff: 105
Waking Staff: 79
Inspection Report
Complaint Investigation
Census: 78
Capacity: 97
Deficiencies: 13
Apr 29, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit triggered by a complaint and incident review on 04/29/2025.
Findings
Multiple deficiencies were identified including failure to assist a resident with toileting, missing signatures on resident contracts, lack of signed statements acknowledging receipt of resident rights, disrespectful treatment of residents, incomplete medical evaluations, improper medication labeling and documentation, and failure to complete required assessments and support plans in a timely manner. Plans of correction were accepted and implemented by 09/29/2025.
Complaint Details
The inspection was complaint-related, triggered by a complaint and incident review on 04/29/2025. The report includes substantiated violations with accepted plans of correction.
Deficiencies (13)
| Description |
|---|
| Resident was left on the toilet for about 25 minutes without assistance after staff left while talking on the phone. |
| Resident-home contract was not signed by the resident. |
| Resident record did not contain a signed statement acknowledging receipt of resident rights and complaint procedures. |
| Staff was observed talking on the phone and leaving resident struggling in bathroom, violating dignity and respect. |
| Resident's most recent medical evaluation did not include Health Status/Cognitive Functioning. |
| OTC medications belonging to resident were not labeled with resident's name. |
| Staff failed to write date, time, and signature on Controlled Inventory Sheet when administering controlled medications. |
| Medication found in cart was not listed on resident's medication administration record (MAR). |
| Resident's medication administration record did not include initials of staff who administered medications. |
| Resident was not educated on the right to refuse medication if a medication error is suspected. |
| Resident was not reassessed after moving to Secured Dementia Care Unit (SDCU). |
| Resident's written cognitive preadmission screening was not completed within 72 hours prior to admission to SDCU. |
| Resident's support plan was not updated within 72 hours of admission to SDCU. |
Report Facts
License Capacity: 97
Residents Served: 78
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 20
Residents with Mobility Need: 28
Residents Age 60 or Older: 78
Total Daily Staff: 106
Waking Staff: 80
Inspection Report
Monitoring
Census: 79
Capacity: 97
Deficiencies: 6
Dec 2, 2024
Visit Reason
The visit was an unannounced partial inspection conducted as a monitoring review of the facility.
Findings
The inspection identified multiple deficiencies related to resident access to bedrooms, medication storage, medication labeling, medication administration documentation, following prescriber's orders, and posting of key-locking device instructions. Plans of correction were accepted and implemented by early February 2025.
Deficiencies (6)
| Description |
|---|
| Resident access to bedroom was impeded by a banner with a 'Do not enter sign' across the entry to their bedroom. |
| Resident blister pack had tape over pill sections and a punctured pill still in the package. |
| Two tubes of medication were open and not labeled with a resident's name in the medication cart. |
| Medication administration record was not properly documented with date, time, or controlled substance count at time of administration. |
| Medication prescribed to resident was sealed and not used despite documentation indicating administration. |
| Directions for operating the home's locking mechanism were not conspicuously posted near the door to the Secure Dementia Care Unit; posted sign was confusing and included incorrect numbers. |
Report Facts
Residents Served: 79
License Capacity: 97
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 20
Current Hospice Residents: 1
Residents Age 60 or Older: 78
Residents Diagnosed with Mental Illness: 45
Residents with Mobility Need: 27
Residents with Physical Disability: 1
Inspection Report
Monitoring
Census: 55
Capacity: 97
Deficiencies: 0
Oct 31, 2024
Visit Reason
The inspection was a monitoring visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, to assess compliance at Mercer Hill at Doylestown.
Findings
No regulatory citations or deficiencies were identified during this unannounced partial inspection.
Report Facts
Residents Served: 55
License Capacity: 97
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 21
Current Hospice Residents: 2
Residents Age 60 or Older: 55
Residents with Mobility Need: 27
Inspection Report
Follow-Up
Census: 78
Capacity: 97
Deficiencies: 12
Sep 18, 2024
Visit Reason
The visit was a partial, unannounced inspection conducted due to an incident, with a follow-up on a previously submitted plan of correction.
Findings
The inspection found multiple deficiencies including lack of a system to safeguard residents' money and property, missing criminal background check documentation for a staff member, insufficient direct care staffing hours, unlocked poisonous materials accessible to residents, missing emergency telephone numbers in a resident room, incomplete medical evaluations, failure to follow prescriber's orders, incomplete resident support plans, missing conspicuous posting of key-locking device instructions, illegible record entries, and incomplete resident record content including missing photographs and personal property inventories. All deficiencies had plans of correction accepted and many were implemented by December 17, 2024.
Deficiencies (12)
| Description |
|---|
| No system in place to safeguard residents' money or property. |
| Criminal background for Staff person A was not located in the employee file. |
| Direct care staffing hours provided were less than required for residents with mobility needs. |
| Less than 75% of personal care service hours were provided during waking hours. |
| Poisonous materials were unlocked and accessible to residents not assessed as safe to use them. |
| Emergency telephone numbers were not posted on or by the telephone in a resident room. |
| Medical evaluation for a resident did not include height, weight, or immunization history. |
| Failure to follow prescriber's orders for medication application; medication containers were sealed despite records indicating administration. |
| Resident support plans did not document how identified medical and personal care needs would be met. |
| Directions for operating key-locking devices were not conspicuously posted near the Secure Dementia Care Unit exit. |
| Entries in a resident’s record were not permanent, legible, dated, or signed; medication record had overwritten time entry. |
| Resident records lacked a recent photograph and inventory of personal property. |
Report Facts
Residents served: 78
Total licensed capacity: 97
Residents in secured dementia care unit: 22
Capacity of secured dementia care unit: 26
Current hospice residents: 3
Residents aged 60 or older: 78
Residents diagnosed with mental illness: 45
Residents with mobility needs: 29
Residents with physical disability: 1
Total daily staff hours: 107
Waking staff hours: 80
Direct care hours required: 107
Direct care hours provided: 101
Direct care hours during waking hours: 71.5
Percentage of direct care hours during waking hours: 67
Inspection Report
Complaint Investigation
Census: 77
Capacity: 97
Deficiencies: 5
Jun 26, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at Mercer Hill at Doylestown on 06/26/2024 and 07/22/2024 to review submitted plans of correction and compliance.
Findings
The inspection found multiple deficiencies including failure to provide required assistance with activities of daily living, resident abuse by staff, incomplete medication administration documentation, and incomplete or unsigned resident support plans. The facility submitted plans of correction which were accepted and implemented.
Complaint Details
The complaint investigation involved allegations of neglect and abuse by staff toward residents, including verbal intimidation and physical mistreatment. The investigation confirmed these allegations, resulting in suspension and termination of the involved staff member. Resident-to-resident altercations causing injury were also documented.
Deficiencies (5)
| Description |
|---|
| Failure to provide resident with assistance with activities of daily living as indicated in the resident’s assessment and support plan. |
| Resident was subjected to verbal and physical abuse by staff, including inappropriate verbal chastisement and physical handling. |
| Medication administration records did not include initials of staff administering medication at specified times. |
| Resident support plan did not document use of bedside mobility devices or how certain needs would be met. |
| Resident support plan was not signed by the resident who participated in its development. |
Report Facts
License Capacity: 97
Residents Served: 77
Staff Total Daily: 106
Waking Staff: 80
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 25
Current Hospice Residents: 4
Residents Diagnosed with Mental Illness: 45
Residents with Mobility Need: 29
Residents Age 60 or Older: 77
Residents Diagnosed with Physical Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Named in findings related to resident abuse and failure to provide assistance. |
Inspection Report
Renewal
Census: 77
Capacity: 97
Deficiencies: 13
Jun 10, 2024
Visit Reason
The inspection was conducted as a renewal and complaint investigation visit to assess compliance with licensing regulations and to review the submitted plan of correction.
Findings
Multiple deficiencies were identified including unsigned resident contracts, missing signed statements acknowledging receipt of resident rights, staff qualification issues, unsafe resident personal equipment, improper medication storage and administration, expired medications, and incomplete resident support plans. The submitted plan of correction was accepted and fully implemented as of 08/01/2024.
Complaint Details
The inspection included a complaint investigation component, but the substantiation status is not explicitly stated in the report.
Deficiencies (13)
| Description |
|---|
| Resident-home contracts for residents #1, #2, and #3 were not signed by the residents. |
| Records for residents #1, #2, and #3 lacked signed statements acknowledging receipt of resident rights and complaint procedures. |
| Direct care staff person A lacked a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Resident #4's bedside mobility devices were not securely attached to the bed frame, creating hazardous entrapment zones. |
| The temperature in the stand-alone refrigerator in the main kitchen was 50°F, exceeding the required maximum of 40°F. |
| The fire extinguisher on the home's bus lacked a tag showing the date of last inspection by a fire safety expert. |
| An insulin pen prescribed for resident #5 was discontinued but still present in the medication refrigerator. |
| Expired Melatonin and improperly stored used Buprenorphine patches were found in medication carts. |
| Resident #5's glucometer was not calibrated correctly and medication administration records for residents #6 and #7 contained discrepancies. |
| Resident #5's accuchek was not performed as prescribed on two occasions; resident #8's medication administration was not properly documented. |
| Staff person D administered blood glucose testing without completing required diabetes education within the past 12 months. |
| Residents #1, #2, and #3 were not educated on their right to refuse medication if they believed there was an error. |
| Resident #4's support plan did not address the use of a bedside mobility device. |
Report Facts
License Capacity: 97
Residents Served: 77
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 20
Hospice Residents: 3
Staffing Hours: 103
Waking Staff: 77
Residents Diagnosed with Mental Illness: 46
Residents with Mobility Need: 26
Residents with Physical Disability: 1
Discontinued Medication Date: May 14, 2024
Expired Medication Date: May 19, 2024
Inspection Dates: 2
Inspection Report
Complaint Investigation
Census: 77
Capacity: 97
Deficiencies: 6
May 13, 2024
Visit Reason
The inspection was an unannounced partial complaint investigation conducted on 05/13/2024 to review compliance with regulatory requirements following a complaint.
Findings
The inspection identified multiple deficiencies including failure to complete annual medical evaluations timely, improper medication storage and documentation, missed medication administrations due to unavailability, incomplete resident support plans regarding medical devices, and illegible record entries. Plans of correction were accepted and fully implemented by 07/19/2024.
Complaint Details
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 05/13/2024. The submitted plan of correction was reviewed and determined to be fully implemented.
Deficiencies (6)
| Description |
|---|
| Resident's most recent annual medical evaluation was not completed within the required timeframe. |
| Failure to implement proper procedures for safe storage, access, security, distribution, and use of medications and medical equipment by trained staff. |
| Medication was administered but not signed off on the narcotics declining inventory log as required. |
| Missed medication administrations due to medication not being available in the home. |
| Resident's support plan did not document use of glasses for vision needs as noted in preadmission screening. |
| Narcotics declining inventory log entries were not legible and had overwritten data without notation. |
Report Facts
License Capacity: 97
Residents Served: 77
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 20
Hospice Residents: 3
Resident Support Staff Hours: 108
Waking Staff Hours: 81
Inspection Report
Complaint Investigation
Census: 72
Capacity: 97
Deficiencies: 0
Jan 30, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial licensing inspection.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related and incident-related; no deficiencies were found and follow-up was not required.
Report Facts
License Capacity: 97
Residents Served: 72
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 15
Hospice Residents: 1
Resident Support Staff: 0
Total Daily Staff: 94
Waking Staff: 71
Residents Age 60 or Older: 72
Residents Diagnosed with Mental Illness: 44
Residents with Mobility Need: 22
Residents with Physical Disability: 47
Inspection Report
Follow-Up
Census: 66
Capacity: 97
Deficiencies: 3
Oct 31, 2023
Visit Reason
The visit was an unannounced partial inspection conducted due to an incident at the facility.
Findings
The inspection found that the facility had validated an incident of financial exploitation by a staff member affecting a resident, failed to inform other potentially affected residents, and failed to provide required assistance with activities of daily living to a resident. The facility submitted a plan of correction which was accepted and fully implemented.
Deficiencies (3)
| Description |
|---|
| Failure to inform other residents potentially harmed by a validated incident of financial exploitation. |
| Failure to provide assistance with toileting, bladder management, bowel management, transferring, grooming, and personal hygiene as indicated in the resident's assessment and support plan. |
| Financial exploitation of a resident by a staff member involving unauthorized use of the resident's credit card. |
Report Facts
Residents Served: 66
License Capacity: 97
Secured Dementia Care Unit Capacity: 26
Residents Served in Dementia Unit: 13
Current Hospice Residents: 1
Residents Diagnosed with Mental Illness: 42
Residents with Mobility Need: 24
Residents Age 60 or Older: 66
Residents with Physical Disability: 44
Unauthorized Charges: 900
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in financial exploitation violation involving resident 1 | |
| Staff member B | Named in failure to provide required assistance with activities of daily living |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 97
Deficiencies: 1
Sep 11, 2023
Visit Reason
The inspection was conducted as a complaint investigation following an unannounced partial inspection on 09/11/2023.
Findings
The report found a violation related to the treatment of residents, specifically an incident where a staff member responded inappropriately to a resident's call for assistance, causing distress. The staff member involved was suspended and subsequently terminated. The facility implemented a zero-tolerance policy on abuse and conducted staff training on abuse prevention and reporting.
Complaint Details
The complaint investigation substantiated an incident of inappropriate staff behavior towards a resident. The staff person involved was suspended and terminated following the investigation. Additional alleged abuse was reported and similarly addressed with suspension and termination.
Deficiencies (1)
| Description |
|---|
| A staff member responded inappropriately to a resident's call for assistance, causing the resident to feel upset and reluctant to request help. |
Report Facts
License Capacity: 97
Residents Served: 65
Secured Dementia Care Unit Capacity: 26
Residents Served in Dementia Unit: 16
Total Daily Staff: 87
Waking Staff: 65
Residents with Mobility Need: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Named in the finding related to inappropriate treatment of a resident and subsequent termination |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 97
Deficiencies: 11
Jun 6, 2023
Visit Reason
The inspection was conducted as a complaint investigation following concerns raised about resident care and compliance with regulations at Mercer Hill at Doylestown.
Findings
The inspection found multiple deficiencies related to resident care including failure to provide assistance with activities of daily living, abuse and neglect concerns, inadequate staffing, late medication administration, lack of proper medical evaluations, and failure to comply with food safety certification and CPR training requirements. Plans of correction were accepted and implemented by August 24, 2023.
Complaint Details
The visit was complaint-related, triggered by concerns about resident neglect, abuse, inadequate assistance with ADLs and IADLs, staffing shortages, and medication administration issues. The complaint was substantiated with multiple violations found.
Deficiencies (11)
| Description |
|---|
| Failure to report incidents to the Department within 24 hours as required. |
| Non-compliance with the PA Department of Agriculture Food Employee Certification Act requiring certified food safety staff. |
| Residents did not receive required assistance with activities of daily living (ADLs) such as personal hygiene, ambulating, toileting, and dressing. |
| Residents did not receive required assistance with instrumental activities of daily living (IADLs) such as bedmaking, reminders, showering, and escorting to meals and exercise. |
| Residents experienced neglect and abuse including excessive wait times for call bell response, being locked outside, and rude staff behavior. |
| Staff failed to treat residents with dignity and respect; staff members were terminated for inappropriate behavior. |
| Resident denied right to reenter room due to locked doors and lack of staff to unlock. |
| Inadequate staffing to meet resident needs, including insufficient medication technicians and caregivers. |
| Insufficient staff trained and certified in first aid and CPR present during inspection dates. |
| Resident medical evaluations incomplete or not updated after medical condition changes. |
| Medications not administered as prescribed, with late administration documented. |
Report Facts
License Capacity: 97
Residents Served: 58
Residents Served in Dementia Unit: 10
Dementia Unit Capacity: 26
Staffing - Total Daily Staff: 72
Staffing - Waking Staff: 54
Call Bell Wait Times: 23
Call Bell Wait Times: 53
Call Bell Wait Times: 13.5
Call Bell Wait Times: 2.02
Average Call Bell Response Time: 23.58
Residents with Mobility Needs: 14
Residents Diagnosed with Mental Illness: 28
Residents with Physical Disability: 35
Inspection Report
Complaint Investigation
Census: 53
Capacity: 97
Deficiencies: 0
May 10, 2023
Visit Reason
The inspection was conducted as a complaint investigation by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 05/10/2023 at Mercer Hill at Doylestown.
Findings
No regulatory citations or deficiencies were identified as a result of this complaint inspection.
Complaint Details
The inspection was complaint-related and no deficiencies or regulatory citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 97
Residents Served: 53
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 13
Hospice Current Residents: 2
Resident Age 60 or Older: 53
Residents with Mobility Need: 13
Total Daily Staff: 66
Waking Staff: 50
Inspection Report
Renewal
Census: 48
Capacity: 97
Deficiencies: 11
Apr 13, 2023
Visit Reason
The inspection was conducted as a renewal and complaint investigation visit to Mercer Hill at Doylestown on 04/13/2023 and 04/14/2023.
Findings
The inspection identified multiple deficiencies including issues with the quality management plan, locking of poisonous materials, food labeling and storage, medication administration errors, support plan documentation, and improper discharge procedures. Plans of correction were accepted and implemented by 08/17/2023.
Complaint Details
The visit included a complaint investigation component as indicated by the inspection reason and findings related to medication errors, discharge procedures, and support plan deficiencies.
Deficiencies (11)
| Description |
|---|
| Quality management plan did not address reportable incident and condition reporting procedures, complaint procedures, staff training, or resident/family councils. |
| Poisonous materials (Tilex and toothpaste) were unlocked and accessible to residents not assessed as capable of safe use. |
| Unlabeled and undated leftover food items found in refrigerator. |
| Outdated prepared beans found in refrigerator past expiration date. |
| Medication administered by staff person who had not completed required medication administration training. |
| Medication error not reported immediately to resident, designated person, and prescriber. |
| Medication storage issues including taping medication blister cards which is unsanitary. |
| Medication administration record inaccuracies and failure to follow prescriber's orders. |
| Preadmission screening form did not document determination that resident's needs can be met by the home. |
| Support plans did not document medical/dental/vision/mental health services or resident needs and responsible persons. |
| Resident discharged against their will without proper physician evaluation or certification. |
Report Facts
License Capacity: 97
Residents Served: 48
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 14
Current Hospice Residents: 3
Residents Diagnosed with Mental Illness: 26
Residents with Physical Disability: 33
Residents with Mobility Need: 17
Inspection Report
Follow-Up
Census: 48
Capacity: 97
Deficiencies: 1
Feb 15, 2023
Visit Reason
The inspection visit on 02/15/2023 was a partial, unannounced follow-up inspection triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction related to documenting how residents' medical, dental, vision, hearing, mental health, or other behavioral care needs will be met was reviewed and determined to be fully implemented. Continued compliance must be maintained.
Deficiencies (1)
| Description |
|---|
| The resident's support plan did not document how identified needs such as ambulating, managing health care, laundry, shopping, transportation, finances, appointments, and sensory needs would be met. |
Report Facts
License Capacity: 97
Residents Served: 48
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 12
Total Daily Staff: 62
Waking Staff: 47
Residents Diagnosed with Mental Illness: 24
Residents with Mobility Need: 14
Residents with Physical Disability: 25
Residents 60 Years or Older: 48
Inspection Report
Follow-Up
Census: 42
Capacity: 97
Deficiencies: 1
Feb 6, 2023
Visit Reason
The inspection visit was a partial, unannounced follow-up to review the implementation of a plan of correction related to an incident at the facility.
Findings
The submitted plan of correction was determined to be fully implemented, specifically addressing the issue of unsigned support plans. Continued compliance must be maintained.
Deficiencies (1)
| Description |
|---|
| Resident #1 participated in the development of his/her support plan but did not sign the support plan. |
Report Facts
License Capacity: 97
Residents Served: 42
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 12
Staffing Hours - Total Daily Staff: 60
Staffing Hours - Waking Staff: 45
Inspection Report
Complaint Investigation
Census: 36
Capacity: 97
Deficiencies: 0
Sep 29, 2022
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was triggered by a complaint, but no deficiencies or regulatory citations were found, indicating the complaint was not substantiated.
Report Facts
Resident Support Staff: 36
Total Daily Staff: 84
Waking Staff: 63
License Capacity: 97
Residents Served: 36
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 8
Residents Age 60 or Older: 36
Residents with Mobility Need: 12
Inspection Report
Complaint Investigation
Census: 32
Capacity: 97
Deficiencies: 2
Sep 13, 2022
Visit Reason
The inspection was conducted as a complaint investigation to review compliance and assess the submitted plan of correction for the facility.
Findings
The submitted plan of correction was determined to be fully implemented. The report includes detailed findings on medication self-administration and medication record keeping deficiencies, with corrective actions accepted and implemented.
Complaint Details
The visit was complaint-related. The plan of correction submitted in response to the complaint was reviewed and found fully implemented.
Deficiencies (2)
| Description |
|---|
| Resident 1 self-administers medications but has not been assessed by a physician, physician’s assistant, or certified nurse practitioner regarding ability to self-administer and need for medication reminders. |
| Resident 2's medication record showed Gabapentin and Metoprolol Suc medications were not administered at the prescribed times on 9/1/22 and 9/2/22. |
Report Facts
Residents Served: 32
License Capacity: 97
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 7
Residents Age 60 or Older: 32
Residents with Mobility Need: 8
Resident Support Staff: 0
Total Daily Staff: 40
Waking Staff: 30
Inspection Report
Complaint Investigation
Census: 25
Capacity: 97
Deficiencies: 14
Aug 15, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation at Mercer Hill at Doylestown.
Findings
Multiple deficiencies were identified related to staff qualifications, orientation, medication administration, resident assessments, support plans, preadmission screenings, and resident record content. Plans of correction were accepted and implemented with audits and ongoing monitoring scheduled.
Complaint Details
The inspection was conducted as a complaint and incident investigation. The report includes substantiated deficiencies related to staff qualifications, training, medication administration, resident assessments, and record keeping.
Deficiencies (14)
| Description |
|---|
| Direct care staff person B did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Staff person B did not receive orientation on fire safety topics including evacuation procedures, staff duties during emergencies, smoking safety, fire extinguisher use, smoke detectors, fire alarms, and emergency telephone use. |
| Staff person B did not complete training within 40 scheduled working hours on resident rights, emergency medical plan, mandatory reporting of abuse and neglect, and reporting of reportable incidents. |
| Resident #1 was administered medications that were not documented at the time of administration. |
| Residents #1, #2, and #3 were not administered certain prescribed medications as ordered but were initialed as given. |
| The home's medication administration training record for staff person A did not include the training completion date. |
| Resident #1's preadmission screening form was not dated, not signed, and lacked determination that needs could be met by the home. |
| Resident #2's preadmission screening form was completed after admission, unsigned, and lacked determination that needs could be met by the home. |
| Resident #1's initial assessment was not dated for completion. |
| Resident #1 and #2's support plans were not signed and dated by the assessor and not signed or marked unable to sign by the resident. |
| Resident #1's written cognitive preadmission screening was completed outside the regulatory time frame; Resident #2's was unsigned and undated. |
| Resident #1's initial support plan was not dated for completion; Resident #2's support plan was completed outside the regulatory time frame. |
| Resident #1's initial support plan did not address cognitive needs. |
| Resident #1, #2, and #3's records did not include incident reports dated in 2022. |
Report Facts
License Capacity: 97
Residents Served: 25
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 5
Total Daily Staff: 32
Waking Staff: 24
Inspection Report
Complaint Investigation
Census: 19
Capacity: 97
Deficiencies: 1
Jun 27, 2022
Visit Reason
The inspection was conducted due to a complaint and monitoring visit to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
The inspection found violations related to staffing and medication administration, specifically that during the overnight shift there were no staff certified to administer 'as needed' medications, causing delays in medication administration to residents.
Complaint Details
The visit was complaint-related and monitoring in nature; no substantiation status was explicitly stated.
Deficiencies (1)
| Description |
|---|
| Residents prescribed 'as needed' medications had to wait until the morning shift to receive them due to no certified staff on the overnight shift to administer medications. |
Report Facts
License Capacity: 97
Residents Served: 19
Secured Dementia Care Unit Capacity: 26
Residents Served in Secured Dementia Care Unit: 1
Total Daily Staff: 20
Waking Staff: 15
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