Pennsylvania Department of Health
 MESSIAH LIFEWAYS AT MESSIAH VILLAGE
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MESSIAH LIFEWAYS AT MESSIAH VILLAGE
Inspection Results For:

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MESSIAH LIFEWAYS AT MESSIAH VILLAGE - 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 July 6, 2026, at Messiah Lifeways at Messiah Village, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.


 Plan of Correction:


Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000
Facility ID #910802

Component 01

Main Building

 

Based on a Medicare/Medicaid Recertification Survey completed on July 6, 2026, it was determined that Messiah Lifeways at Messiah Village had deficiencies that have the potential for minimal harm as related to 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 (000), unprotected noncombustible structure, which 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 - 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 document review, observation and interview, it was determined the following item 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 component. Findings include: 1. Review of documentation, observation and interview on July 6, 2026, between 8:45 AM and 10:30 AM, revealed the facility lacked documentation verifying the fire alarm system, which was upgraded October 2025,with no plans submitted to and approved by Department of Health Plan Review. Interview at the time of the exit conference with the Administrator, Life Safety Manager and Facilities Manager on July 6, 2026, at 2:00 PM, confirmed the facility did not receive occupancy approval, prior to the upgrade of the fire alarm system.
 Plan of Correction - To be completed: 08/31/2026

The facility immediately contacted the Pennsylvania Department of Health Division of Safety Inspection/Plan Review and is submitting all required documentation for retroactive Plan Review approval of the fire alarm system upgrade. All current work on the fire alarm system upgrade has ceased until Plan Review approval is received. On July 31, 2026, the facility implemented a Construction and Life Safety compliance program to ensure all future renovations, construction, and Life Safety Code projects comply with the Pennsylvania Department of Health requirements before work begins or a project is placed into service. The Administrator and Facilities Management team will maintain a Construction and Life Safety project log to verify and document all required approvals obtained before construction and occupancy.

The Administrator will audit the Construction and Life Safety project log monthly for six months to ensure all required approvals were obtained before construction or occupancy. Audits will then continue every six months for any new construction projects that need to be submitted. Any identified variances will be corrected immediately and monitoring will continue until compliance is demonstrated. Audit results will be presented to the Quality Assurance and Performance Improvement (QAPI) Committee for review.

Date of compliance: August 31, 2026
Initial comments:Name: CHAPEL ADDITION - Component: 02 - Tag: 0000
Facility ID #910802

Component 02

Chapel Addition

 

Based on a Medicare/Medicaid Recertification Survey completed on July 6, 2026, it was determined that Messiah Lifeways at Messiah Village had deficiencies that have the potential for minimal harm as related to 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 two-story, Type II (111), protected noncombustible structure, with a basement, which 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: CHAPEL ADDITION - Component: 02 - 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 document review, observation and interview, it was determined the following item 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 component. Findings include: 1. Review of documentation, observation and interview on July 6, 2026, between 8:45 AM and 10:30 AM, revealed the facility lacked documentation verifying the fire alarm system, which was upgraded October 2025, with no plans submitted to and approved by Department of Health Plan Review. Interview at the time of the exit conference with the Administrator, Life Safety Manager and Facilities Manager on July 6, 2026, at 2:00 PM, confirmed the facility did not receive occupancy approval, prior to the upgrade of the fire alarm system.
 Plan of Correction - To be completed: 08/31/2026

The facility immediately contacted the Pennsylvania Department of Health Division of Safety Inspection/Plan Review and is submitting all required documentation for retroactive Plan Review approval of the fire alarm system upgrade. All current work on the fire alarm system upgrade has ceased until Plan Review approval is received. On July 31, 2026, the facility implemented a Construction and Life Safety compliance program to ensure all future renovations, construction, and Life Safety Code projects comply with the Pennsylvania Department of Health requirements before work begins or a project is placed into service. The Administrator and Facilities Management team will maintain a Construction and Life Safety project log to verify and document all required approvals obtained before construction and occupancy.

The Administrator will audit the Construction and Life Safety project log monthly for six months to ensure all required approvals were obtained before construction or occupancy. Audits will then continue every six months for any new construction projects that need to be submitted. Any identified variances will be corrected immediately and monitoring will continue until compliance is demonstrated. Audit results will be presented to the Quality Assurance and Performance Improvement (QAPI) Committee for review.

Date of compliance: August 31, 2026
Initial comments:Name: ENHANCED LIVING BUILDING - Component: 03 - Tag: 0000
Facility ID #910802

Component 03

Enhanced Living Building

 

Based on a Medicare/Medicaid Recertification Survey completed on July 6, 2026, it was determined that Messiah Lifeways at Messiah Village had deficiencies that have the potential for minimal harm as related to 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 three-story, Type II (111), protected noncombustible structure, which 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: ENHANCED LIVING BUILDING - Component: 03 - 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 document review, observation and interview, it was determined the following item 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 component. Findings include: 1. Review of documentation, observation and interview on July 6, 2026, between 8:45 AM and 10:30 AM, revealed the facility lacked documentation verifying the fire alarm system, which was upgraded October 2025, with no plans submitted to and approved by Department of Health Plan Review. Interview at the time of the exit conference with the Administrator, Life Safety Manager and Facilities Manager on July 6, 2026, at 2:00 PM, confirmed the facility did not receive occupancy approval, prior to the upgrade of the fire alarm system.
 Plan of Correction - To be completed: 08/31/2026

The facility immediately contacted the Pennsylvania Department of Health Division of Safety Inspection/Plan Review and is submitting all required documentation for retroactive Plan Review approval of the fire alarm system upgrade. All current work on the fire alarm system upgrade has ceased until Plan Review approval is received. On July 31, 2026, the facility implemented a Construction and Life Safety compliance program to ensure all future renovations, construction, and Life Safety Code projects comply with the Pennsylvania Department of Health requirements before work begins or a project is placed into service. The Administrator and Facilities Management team will maintain a Construction and Life Safety project log to verify and document all required approvals obtained before construction and occupancy.

The Administrator will audit the Construction and Life Safety project log monthly for six months to ensure all required approvals were obtained before construction or occupancy. Audits will then continue every six months for any new construction projects that need to be submitted. Any identified variances will be corrected immediately and monitoring will continue until compliance is demonstrated. Audit results will be presented to the Quality Assurance and Performance Improvement (QAPI) Committee for review.

Date of compliance: August 31, 2026

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