Pennsylvania Department of Health
MT. HOPE NAZARENE RETIREMENT COMMUNITY
Building Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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MT. HOPE NAZARENE RETIREMENT COMMUNITY - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

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

Facility ID #134002
Component 01
Main Building

Based on a Relicensure Survey completed on October 29, 2025, it was determined that Mt. Hope Nazarene Retirement Community was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

This is a two-story, Type V (000), unprotected wood frame structure, without a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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 S-tags, but are deficient.

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 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. Observation on October 29, 2025, at 11:59 AM, revealed the facility constructed a new storage room at the end of the Zone 3 Hall. This storage room is accessible only from the exterior of the facility, is partially constructed of combustible material, contains new electrical wiring and fixtures and is not sprinklered.

Interview with the Maintenance Supervisor on October 29, 2025, at 11:59 AM, confirmed the construction without plan approval.

Plan of Correction - To be completed: 11/12/2025

The facility unintentionally enclosed an outdoor space under the concrete ramp outside and against the brick wall in Zone 3 for placement of extra outbreak COVID supplies to be stored due to a space constraint.
The entire area was dismantled on November 3rd 2025, of the metal front frame, the door, the door frames, the fixtures and the electrical wiring was removed.
No new structures on the outside or inside of the facility will be built unless Plan Review has been conducted with Life Safety Plan Review Department of Health.
All future building plans will be started by the Maintenance Director and reviewed by the Administrator or designee to as an added quality assurance and brought to the next two cycles of the Quality Improvement Meeting. An auditing sheet will be provided for the future projects that may come up for need of submittal to plan review and will be reviewed weekly for one month, monthly for 5 months.

NFPA 101 STANDARD Building Construction Type and Height:

Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting two of two floors within the component.

Findings include:

1. Observation on October 29, 2025, at 10:00 AM, revealed the building is a fully sprinklered, two-story, unprotected wood frame structure. This type of construction is not permitted to be more than one story.

Interview with the Maintenance Supervisor on October 29, 2025, at 10:00 AM, confirmed the construction type and height is not permitted in healthcare.

Plan of Correction - To be completed: 11/10/2025

Mt Hope Nazarene Retirement Community is requesting that a Fire Safety Evaluation System being completed by the Division of Life Safety for this fully sprinklered and alarmed building with an annunciator panel. In addition, a Generator which runs all electrical in the building is present.

The FSES review for the building will be brought to the quarterly Quality Assurance programs for the next two quarterly meetings.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

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

Based on document review and interview, it was determined the facility failed to provide documentation verifying smoke detectors had been subjected to a functional inspection within the previous twelve months, affecting one of three smoke compartments within the component.

Findings include:

1. Review of documentation on October 29, 2025, at 10:09 AM, revealed the facility lacked documentation verifying the Zone 2, floor 2 smoke detector within the Elevator Shaft had been functionally tested, since February 29, 2024.

Interview with the Maintenance Supervisor on October 29, 2025, at 10:09 AM, confirmed the lack of documentation verifying all smoke detectors had been functionally tested within the previous twelve months.

Plan of Correction - To be completed: 11/14/2025

Floor 2 smoke detector within the Elevator Shaft had been functionally tested, since was functionally tested on Friday November 7 2025. The Elevator Technician from Penn Elevator arrived at the facility and brought the elevator to a position where the Simplex Grinnell Johnson Control inspector went through the entire functional tests on the smoke detectors and areas around it. Both technicians worked together and stated that all detectors were in working order.

The Administrator or designee will audit the technicians reporting of the functional testing of the smoke detectors in the building during functional testing intervals that are conducted in accordance with NFPA 70 and 72 regulation. Results will be placed on a spread sheet and reported on as these checks are conducted biannually as one functional test and one visual test.
These spread sheet will be presented at the next three quarters of Quality Improvement Meetings.

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