19 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Mt Carmel, PA
1-star overall rating with 1-star inspections with abuse icon flag with 19 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2616 Locust Gap Highway, Mt Carmel, PA
(570) 339-2501
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
119
Certified beds
Average residents
105
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Gabriel Sebbag & The Samara Family
Operator or chain grouping
Approved since
1983-07-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 1 overall / 1 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.42
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.23
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.28
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
2.95
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
3.31
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
6,124
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.93
Composite VBP score used to determine payment impact.
Payment multiplier
0.9880
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.66
Baseline 16.17% · Performance 19.74% · Measure score 3.66 · Achievement 3.66 · Improvement 0
Healthcare-associated infections
3.41
Baseline 6.57% · Performance 6.82% · Measure score 3.41 · Achievement 3.41 · Improvement 0
Total nurse turnover
6.5
Baseline 26.80% · Performance 37.11% · Measure score 6.5 · Achievement 6.5 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.86 hours · Performance 3.21 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.98% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 112 · Observed rate 6.25% · Lower 95% interval 6.07% |
| Discharge to community | 35.95% |
50.57%
14.6 pts worse
|
Worse than the National Rate · Eligible stays 111 · Observed rate 27.03% · Lower 95% interval 28.11% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 67 · Denominator 67 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 67 |
| Discharge self-care score | 69.23% |
53.69%
15.5 pts better
|
Numerator 36 · Denominator 52 |
| Discharge mobility score | 71.15% |
50.94%
20.2 pts better
|
Numerator 37 · Denominator 52 |
| Pressure ulcers or injuries, new or worsened | 1.49% |
2.29%
0.8 pts better
|
Numerator 1 · Denominator 67 · Adjusted rate 1.28% |
| Healthcare-associated infections requiring hospitalization | 6.81% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 5.8% · Lower 95% interval 3.71% |
| Staff COVID-19 vaccination coverage | 1.48% |
8.2%
6.7 pts worse
|
Numerator 2 · Denominator 135 |
| Staff flu vaccination coverage | 19.42% |
42%
22.6 pts worse
|
Numerator 27 · Denominator 139 |
| Discharge function score | 67.31% |
56.45%
10.9 pts better
|
Numerator 35 · Denominator 52 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 29 · Denominator 29 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 30% |
25.2%
4.8 pts better
|
Numerator 12 · Denominator 40 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.7
0.2 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.2
0.1 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.8% |
86.9%
4.9 pts better
|
93.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 96.0% · Q2 94.4% · Q3 82.8% · Q4 93.7% · 4Q avg 91.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.1% |
93.5%
3.6 pts better
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.2%
1 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 5.6% · Q3 4.3% · Q4 3.2% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.7% |
6.5%
1.8 pts better
|
11.4%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 6.6% · Q3 2.3% · Q4 3.3% · 4Q avg 4.7% |
| Percentage of long-stay residents who lose too much weight | 9.1% |
6.5%
2.6 pts worse
|
5.4%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 14.6% · Q3 8.0% · Q4 5.6% · 4Q avg 9.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.3% |
19.9%
7.6 pts better
|
19.6%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 13.1% · Q3 12.4% · Q4 15.4% · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.8% |
18.7%
3.9 pts better
|
16.7%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 12.0% · Q3 18.4% · Q4 18.5% · 4Q avg 14.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.1% |
19.6%
1.5 pts worse
|
16.3%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 13.7% · Q3 24.8% · Q4 18.7% · 4Q avg 21.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.3% |
18.3%
1 pts better
|
14.9%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 11.5% · Q3 20.2% · Q4 14.9% · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.9%
0.3 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
1.7%
1.5 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 4.3% · Q4 5.4% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.2% |
26.4%
1.8 pts worse
|
19.8%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 31.4% · Q3 24.4% · Q4 30.7% · 4Q avg 28.2% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
5.3%
2.6 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 1.9% · Q3 2.6% · Q4 1.4% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.7% |
68.9%
10.8 pts better
|
81.7%
2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 84.4% · Q3 73.3% · Q4 67.1% · 4Q avg 79.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.4% |
9.8%
6.6 pts worse
|
12.0%
4.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.4% · Observed 15.4% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.5%
0.5 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 1.7% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.9% |
68.7%
30.2 pts better
|
79.7%
19.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.3% |
23.1%
2.2 pts worse
|
23.9%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.3% · Observed 24.6% · Expected 23.2% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (7 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (8 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-09-09
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-09
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-09-09
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-09
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-09-03
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-09-03
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-03
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-03
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-25
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-09-25
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-25
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-25
Inspection history
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Not marked corrected
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-26
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-08-26
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-08-26
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-08-26
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-08-26
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-08-26
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-26
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-08-26
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-08-26
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-26
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-08-26
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-26
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-08-26
Health
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.
Corrected 2025-08-26
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2025-08-26
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-04
Health
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.
Corrected 2025-04-04
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-25
Health
Post nurse staffing information every day.
Not marked corrected
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-26
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-12-26
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-26
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-11-06
Health
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.
Corrected 2024-09-27
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-27
Health
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.
Corrected 2024-09-27
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-09-27
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2024-09-27
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-27
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-09-27
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-09-27
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-09-27
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-09-27
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-27
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-27
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-27
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-09-27
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-09-27
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-04-23
Health
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.
Corrected 2024-02-19
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-02-19
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-27
Health
Provide activities to meet all resident's needs.
Corrected 2023-10-27
Health
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.
Corrected 2023-10-27
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-10-27
Health
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.
Corrected 2023-10-27
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-27
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-10-27
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-10-27
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2023-10-27
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Organization
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