Pennsylvania Department of Health
MOUNT CARMEL SENIOR LIVING COMMUNITY
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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MOUNT CARMEL SENIOR LIVING COMMUNITY - 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 25, 2026, at Mount Carmel Senior Living Community, 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# 137802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 25, 2026, it was determined that Mount Carmel Senior Living Community 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 V (000), unprotected, wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

Least serious 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 has the potential for causing no more than a minor negative impact on the resident.

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

28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.

35 P.S. 448.808. Issuance of license.

(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.

Based on observation and interview, it was determined the following item(s) did not meet the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the facility.

Findings include:

1. Observation on June 25, 2026, at 10:45 a.m., revealed the facility failed to seek State approval for the installation of a new, Special Locking Arrangement System (SLA) within a portion of the facility.

Exit interview on June 25, 2026, between 11:50 a.m., and 12:00 p.m., with the Facility Administrator, confirmed the above deficiency.

Plan of Correction - To be completed: 08/04/2026

1. This is a past event that is unable to be corrected.
2. Message has been left with PA DOH Plan Review to discuss Special Locking Arrangement System (SLA) project completion and the lack of prior notification for Plan Review and State approval
3. Regional Facilities Operations Director to complete education regarding SLA plan review/requirement with NHA and Maintenance Director
4. All future changes to construction and operations will be submitted to State for plan review; results of findings to QAPI
5. Date of compliance 08/04/2026

NFPA 101 STANDARD Exit Signage:

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based on observation and interview, it was determined the facility failed to install and maintain exit signage in one location, affecting one of one floor.

Findings include:

1. Observation on June 25, 2026, at 10:44 a.m., revealed the exit access corridor area entering the Therapy Building lacked illuminated exit signage.

Exit interview on June 25, 2026, between 11:50 a.m., and 12:00 p.m., with the Facility Administrator, confirmed the exit signage deficiency.

Plan of Correction - To be completed: 08/04/2026

1. This is a past event which cannot be corrected
2. Exit signage to be installed in the corridor area entering the Therapy portion of facility; house audit to be completed to ensure all other Exit signage is in place
3. Education completed with Maintenance Department on K0293 regulation
4. Audit of Exit signage in place and functioning to be completed weekly x2 weeks; then monthly x2 months with results to QAPI
5. Date of compliance 08/04/2026

NFPA 101 STANDARD Corridor - Doors:

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.

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor openings in three locations, affecting one of one floor.

Findings include:

1. Observation on June 25, 2026, between 10:50 a.m., and 11:20 a.m., revealed the following:

a. 10:50 a.m., the Activities Room door was held open by unapproved means.
b. 11:18 a.m., the distance between the Ambulance Linen Closet doors exceeded one-eighth-inch.
c. 11:20 a.m., the Administrator's Office door was not smoke-tight.

Exit interview on June 25, 2026, between 11:50 a.m., and 12:00 p.m., with the Facility Administrator, confirmed the corridor opening deficiencies.

Plan of Correction - To be completed: 08/04/2026

1. This is a past event which cannot be corrected
2. A. The Activity Door was corrected during survey
B. The ambulance linen closet to be corrected to not exceed one-eighth-inch
C. The Administrator office door that enters into the adjacent office to be repaired to ensure smoke-tight
3. Education regarding K0363 regulation to be completed with Maintenance Department
4. Audits to be completed weekly x2 weeks, then monthly x2 months on Activity Door, Ambulance Linen Closet Door and Administrator Door to ensure no further non-compliance; results to QAPI
5. Date of compliance 08/04/2026

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the generator set in one instance, affecting one of one floor.

Findings include:

1. Observation on June 25, 2026, at 11:30 a.m., revealed the facility lacked current, annual fuel quality testing data for the generator set.

Exit interview on June 25, 2026, between 11:50 a.m., and 12:00 p.m., with the Facility Administrator, confirmed the generator set deficiency.

Plan of Correction - To be completed: 08/04/2026

1. This is a past event which cannot be corrected
2. Documentation required for annual fuel quality testing data for generator set missing during survey has been provided by contracted service providers
3. Education regarding K0918 regulation to be completed with Maintenance Department
4. Audit to be completed by NHA/Designee monthly x3 months with results to QAPI
5. Date of compliance 08/04/2026

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