MOUNT CARMEL SENIOR LIVING COMMUNITY Inspection Report, Violations & Safety Grade (MT CARMEL, Pennsylvania)

2616 LOCUST GAP HIGHWAY, MT CARMEL, Pennsylvania 17851

Phone: 5703392501

CMS Overall:1/5

Overview & Bed Count

Certified Beds

119

Avg Residents/Day

109.1

Ownership

For profit - Limited Liability company

Provider Type

Medicare and Medicaid

County

Northumberlnd

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

Yes

CMS Star Ratings

Overall1/5

Health1/5

Staffing1/5

Quality3/5

Nurse Staffing Check

Metric	This Facility	Pennsylvania Avg	Difference
RN Hours per Resident per Day	0.48	0.78	-0.29
Total Nurse Hours per Resident per Day	3.08	3.90	-0.82
CMS Staffing Rating	1/5	3.1/5	-
Nursing Staff Turnover	50.5%	44.6%	-

Health Citation History

64 health citations on record

Date	Category	Description	Severity
2026-06-17	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	F – Moderate Harm Potential
2026-06-17	Resident Rights Deficiencies	Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.	E – Moderate Harm Potential
2026-06-17	Resident Assessment and Care Planning Deficiencies	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	E – Moderate Harm Potential
2026-06-17	Resident Rights Deficiencies	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	D – Moderate Harm Potential
2026-06-17	Resident Rights Deficiencies	Allow residents to self-administer drugs if determined clinically appropriate.	D – Moderate Harm Potential
2026-06-17	Resident Rights Deficiencies	Reasonably accommodate the needs and preferences of each resident.	D – Moderate Harm Potential
2026-06-17	Resident Rights Deficiencies	Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.	D – Moderate Harm Potential
2026-06-17	Resident Rights Deficiencies	Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	D – Moderate Harm Potential
2026-06-17	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.	D – Moderate Harm Potential
2026-06-17	Resident Assessment and Care Planning Deficiencies	PASARR screening for Mental disorders or Intellectual Disabilities	D – Moderate Harm Potential
2026-06-17	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2026-06-17	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	D – Moderate Harm Potential
2026-06-17	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential
2026-06-17	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	D – Moderate Harm Potential
2026-06-17	Quality of Life and Care Deficiencies	Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.	D – Moderate Harm Potential
2026-06-17	Pharmacy Service Deficiencies	Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.	D – Moderate Harm Potential
2026-06-17	Nutrition and Dietary Deficiencies	Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.	D – Moderate Harm Potential
2026-06-17	Nutrition and Dietary Deficiencies	Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.	D – Moderate Harm Potential
2026-06-17	Resident Assessment and Care Planning Deficiencies	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	D – Moderate Harm Potential
2026-06-17	Administration Deficiencies	Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.	D – Moderate Harm Potential
2026-06-17	Nutrition and Dietary Deficiencies	Dispose of garbage and refuse properly.	C – Minimal Harm Potential
2026-06-17	Nursing and Physician Services Deficiencies	Post nurse staffing information every day.	B – Minimal Harm Potential
2025-12-03	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	G – Actual Harm
2025-07-18	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	F – Moderate Harm Potential
2025-07-18	Resident Rights Deficiencies	Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.	E – Moderate Harm Potential
2025-07-18	Quality of Life and Care Deficiencies	Provide care or services that was trauma informed and/or culturally competent.	E – Moderate Harm Potential
2025-07-18	Nursing and Physician Services Deficiencies	Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.	E – Moderate Harm Potential
2025-07-18	Resident Rights Deficiencies	Keep residents' personal and medical records private and confidential.	D – Moderate Harm Potential
2025-07-18	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.	D – Moderate Harm Potential
2025-07-18	Resident Assessment and Care Planning Deficiencies	Ensure each resident receives an accurate assessment.	D – Moderate Harm Potential
2025-07-18	Resident Assessment and Care Planning Deficiencies	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	D – Moderate Harm Potential
2025-07-18	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2025-07-18	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	D – Moderate Harm Potential
2025-07-18	Quality of Life and Care Deficiencies	Assist a resident in gaining access to vision and hearing services.	D – Moderate Harm Potential
2025-07-18	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential
2025-07-18	Quality of Life and Care Deficiencies	Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.	D – Moderate Harm Potential
2025-07-18	Pharmacy Service Deficiencies	Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	D – Moderate Harm Potential
2025-07-18	Environmental Deficiencies	Provide bedrooms that don't allow residents to see each other when privacy is needed.	D – Moderate Harm Potential
2025-03-18	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	G – Actual Harm
2025-03-18	Resident Rights Deficiencies	Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	E – Moderate Harm Potential
2025-03-18	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	D – Moderate Harm Potential
2025-01-02	Nursing and Physician Services Deficiencies	Post nurse staffing information every day.	C – Minimal Harm Potential
2024-11-25	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	E – Moderate Harm Potential
2024-11-25	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2024-11-25	Quality of Life and Care Deficiencies	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	D – Moderate Harm Potential
2024-10-10	Nutrition and Dietary Deficiencies	Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.	E – Moderate Harm Potential
2024-08-23	Quality of Life and Care Deficiencies	Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.	E – Moderate Harm Potential
2024-08-23	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	E – Moderate Harm Potential
2024-08-23	Quality of Life and Care Deficiencies	Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.	E – Moderate Harm Potential
2024-08-23	Nursing and Physician Services Deficiencies	Observe each nurse aide's job performance and give regular training.	E – Moderate Harm Potential

Showing 50 of 64 citations.

Fire Safety Citation History

12 fire safety citations on record

Date	Category	Description	Severity
2026-06-17	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	E – Moderate Harm Potential
2026-06-17	Construction Deficiencies	Meet other general requirements.	C – Minimal Harm Potential
2026-06-17	Egress Deficiencies	Have properly located and lighted "Exit" signs.	C – Minimal Harm Potential
2026-06-17	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	C – Minimal Harm Potential
2025-07-18	Egress Deficiencies	Keep aisles, corridors, and exits free of obstruction in case of emergency.	E – Moderate Harm Potential
2025-07-18	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	E – Moderate Harm Potential
2025-07-18	Smoke Deficiencies	Properly select, install, inspect, or maintain portable fire extinguishes.	E – Moderate Harm Potential
2025-07-18	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	E – Moderate Harm Potential
2024-08-23	Construction Deficiencies	Meet requirements for sections of health care facilities separated by fire resistive construction.	E – Moderate Harm Potential
2024-08-23	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	E – Moderate Harm Potential
2024-08-23	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	E – Moderate Harm Potential
2024-08-23	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	C – Minimal Harm Potential

Total Penalties & Fines

$16,055

Total Fine Amount (CMS)

Number of Fines

Total Penalties

Date	Type	Fine Amount	Payment Denial
2025-03-18	Fine	$16,055	-

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Need Help Finding Safe Care?

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3-Year Complete Report ($19)

Advisor service is free for families. We may receive referral compensation.