Pennsylvania Department of Health
PHOEBE ALLENTOWN HEALTH CARE CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 69 surveys for this facility. Please select a date to view the survey results.

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PHOEBE ALLENTOWN HEALTH CARE CENTER - 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 June 22-23, 2026, at Phoebe Allentown Health Care Center, 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# 161302
Component 01
West Wing

Based on a Medicare/Medicaid Recertification Survey completed on June 22-23, 2026, it was determined that Phoebe Allentown Healthcare Center 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 three story, Type II (000), unprotected, noncombustible building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

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.

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 01 - Component: 01 - Tag: 0161

Based on documentation review, observation, and interview, the facility failed to maintain building construction requirements, affecting four of four floors within this component.

Findings include:

1. Observation on July 23, 2025, between 9:00 am, and 10:00 am, revealed the facility exceeded maximum allowable story height for this type of construction.

Exit interview with the Maintenance Manager and the Facilities Manager on June 23, 2026, at 11:00 am, confirmed the building construction deficiency.

Plan of Correction - To be completed: 08/03/2026

The facility wishes to continue the approved FSES on file and requests an inspection to occur at a date to be scheduled by the DOH life Safety Team to renew the FSES.

NFPA 101 STANDARD Cooking Facilities:

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on documentation review, observation, and interview, it was determined the facility failed to maintain cooking facilities in one instance, affecting one of four floors.

Findings include:

1. Observation on June 22, 2026, at 10:45 a.m., revealed the facility lacked one of two required kitchen suppression system testing and maintenance inspections.

Exit interview with the Maintenance Manager and the Facilities Manager on June 23, 2026, at 11:00 am, confirmed the cooking facilities deficiency.

Plan of Correction - To be completed: 08/03/2026

Vendor for fire suppression testing and servicing was notified on 6/29/26, and we submitted a request for services and inspections to be scheduled and this is the purchase order number (PO#33210).

We will audit this inspection on a quarterly basis for the next quarter to make sure we are compliant with the inspections needed.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on documentation review, observation, and interview, it was determined the facility failed to maintain the automatic sprinkler system in multiple locations, affecting four of four floors.

Findings include:

1. Observation on June 23, 2026, at 9:20 am, 2nd floor, revealed 2 unsealed penetrations of the corridor ceiling near the soiled utility room.

2. Observation on June 23, 2026, at 10:40 a.m., revealed the facility lacked automatic sprinkler system testing and inspection data for three of the previous four quarters (12 month period).

Exit interview with the Maintenance Manager and the Facilities Manager on June 23, 2026, at 11:00 am, confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 08/03/2026

1. Penetrations were sealed on 06/23/26. Educate staff on the correct procedures and usage of fire stopping to be completed by 08/03/2026. Perform monthly rounds for a quarter to make sure we are compliant and report out on our findings in our monthly QAPI meeting.

2. Scheduled all sprinkler and suppression servicing and inspections with Comunale Fire systems on 4/17/26, PO#33210. We will audit this on a quarterly basis for the next quarter to make sure we are compliant with the inspections needed.

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000

Facility ID# 161302
Component 02
East Wing

Based on a Medicare/Medicaid Recertification Survey completed June 22-23, 2026, it was determined that Phoebe Allentown Health Care Center 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 three story, Type II (000), unprotected, noncombustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Multiple Occupancies:

Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain one common wall, affecting one of four floors.

Findings include:

1. Observation on June 22, 2026, at 2:00 p.m., revealed the single, "short" common wall door with the tunnel required adjustment to fully latch within the door frame assembly.

Exit interview with the Maintenance Manager and the Facilities Manager on June 23, 2026, at 11:00 am, confirmed the common wall deficiency.

Plan of Correction - To be completed: 08/03/2026

Door latching was corrected on 07/01/2026 and is fully latching within the door frame assembly. Education for staff in procedures for inspecting fire and smoke door assemblies to be completed by 8/03/26. Perform monthly rounds for a quarter to make sure we are compliant and report out on our findings in our monthly QAPI meeting.

NFPA 101 STANDARD Building Construction Type and Height:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0161

Based on documentation review, observation, and interview, the facility failed to maintain building construction requirements, affecting four of four floors within this component.

Findings include:

1. Observation on June 22, 2026, between 1:00 p.m., and 2:00 p.m., revealed the facility exceeded maximum allowable story height for this type of construction.

Exit interview with the Maintenance Manager and the Facilities Manager on June 23, 2026, at 11:00 am, confirmed the building construction deficiency.

Initial comments:Name: BUILDING 03 - Component: 03 - Tag: 0000

Facility ID# 161302
Component 03
Trexler Wing

Based on a Medicare/Medicaid Recertification Survey completed on June 22-23, 2026, it was determined that Phoebe Allentown Healthcare Center 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 three story, Type II (222), fire resistive building, with basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in one location, affecting one of four floors.

Findings include:

1. Observation on June 22, 2026, at 1:45 pm, Basement Level, revealed 2 unsealed penetrations of the rated ceiling assembly within the housekeeping storage corridor.

Exit interview with the Maintenance Manager and the Facilities Manager on June 23, 2026, at 11:00 am, confirmed the unsealed penetrations.

Plan of Correction - To be completed: 08/03/2026

Penetrations were sealed with fire stopping on 6/24/26. Educate staff on the correct procedures and usage of fire stopping. Completed by 08/03/2026. Perform monthly rounds for a quarter to make sure we are compliant and report out on our findings in our monthly QAPI meeting.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0923

Based on observation and interview, the facility failed to properly secure oxygen cylinders in two locations, affecting two of four floors.

Findings include:

1. Observation on June 22, 2026, between 2:02 pm, and 2:17 pm, revealed the following:

a. At 2:02 pm, 1st floor, 3 oxygen "E" cylinders, and 1 oxygen "D" cylinder being stored, in the oxygen storage room, were being stored on the floor without support.
b. At 2:17 pm, 2nd floor, 1 oxygen "E" cylinders being stored, in the oxygen storage room, were being stored on the floor without support.

Exit interview with the Maintenance Manager and the Facilities Manager on June 23, 2026, at 11:00 am, confirmed the unsecured oxygen cylinders storage.

Plan of Correction - To be completed: 08/03/2026

Oxygen tank storage corrected on 06/22/26. Education to staff regarding proper oxygen tank storage and handling of portable gas cylinders will be conducted. Perform monthly rounds for a quarter to make sure we are compliant and report out on our findings in our monthly QAPI meeting.

Initial comments:Name: BUILDING 04 - Component: 04 - Tag: 0000

Facility ID# 161302
Component 04
Annex Wing

Based on a Medicare/Medicaid Recertification Survey completed June 22-23, 2026, it was determined that Phoebe Allentown Health Care Center 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 three story, Type II (222), fire resistive building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Observations:
Name: BUILDING 04 - Component: 04 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of four floors.

Findings include:

1. Observation on June 22, 2026, at 1:30 p.m., revealed an escutcheon plate was missing from an automatic sprinkler head assembly, located within the basement-level, Laundry Dryer Room.

Exit interview with the Maintenance Manager and the Facilities Manager on June 23, 2026, at 11:00 am, confirmed the automatic sprinkler system deficiency.

Plan of Correction - To be completed: 08/03/2026

Escutcheon plate is being ordered through Communale Fire Systems and will be installed upon arrival. We will audit this quarterly for the next quarter to make sure we are compliant.

NFPA 101 STANDARD Corridor - Doors:

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: BUILDING 04 - Component: 04 - Tag: 0363

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

Findings include:

1. Observation on June 22, 2026, between 1:40 p.m., and 1:55 p.m., revealed the following Resident Room doors were not smoke-tight:

a. 1:40 p.m., L315.
b. 1:42 p.m., L311.
c. 1:55 p.m., L111.

Exit interview with the Maintenance Manager and the Facilities Manager on June 23, 2026, at 11:00 am, confirmed the corridor opening deficiencies.

Plan of Correction - To be completed: 08/03/2026

Work order was placed on 06/29/26 for resident room doors to be corrected and smoke-tight to be corrected by 07/07/2026. Perform monthly rounds for a quarter to make sure we are compliant and report out on our findings in our monthly QAPI meeting

Initial comments:Name: BUILDING 05 - Component: 05 - Tag: 0000

Facility ID# 161302
Component 05
Home Center/Activities Building

Based on a Medicare/Medicaid Recertification Survey completed on June 22-23, 2026, it was determined that Phoebe Allentown Healthcare Center 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 three story, Type II (000), unprotected, noncombustible building, with basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

Observations:
Name: BUILDING 05 - Component: 05 - Tag: 0161

Based on documentation review, observation, and interview, the facility failed to maintain building construction requirements, affecting four of four floors within this component.

Findings include:

1. Observation on June 23, 2026, between 9:00 am, and 10:00 am, revealed the facility exceeded maximum allowable story height for this type of construction.

Exit interview with the Maintenance Manager and the Facilities Manager on June 23, 2026, at 11:00 am, confirmed the building construction deficiency.

NFPA 101 STANDARD Doors with Self-Closing Devices:

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:
Name: BUILDING 05 - Component: 05 - Tag: 0223

Based on observation and interview, it was determined the facility failed to maintain doors with self-closing devices in two locations, affecting four of four floors.

Findings include:

1.Observation on June 23, 2026, between 9:40 am, and 9:43 am, revealed the following:

a. At 9:40 am, Moyer Hall, double doors failed to positively latch together.
b. At 9:43 am, Moyer Hall, storage room door, was being held open by an unauthorized means. (metal stanchion).

Exit interview with the Maintenance Manager and the Facilities Manager on June 23, 2026, at 11:00 am, confirmed the self-closure door deficiencies.

Plan of Correction - To be completed: 08/03/2026

A. Double doors were corrected to fully latch together on 07/02/2026. B. Educate staff on fire safety to include holding doors open with unauthorized means. Will Include this information when onboarding new staff. Make this information available when staff attend their onboarding orientation. Perform monthly rounds for a quarter to make sure we are compliant and report out on our findings in our monthly QAPI meeting.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations:
Name: BUILDING 05 - Component: 05 - Tag: 0225

Based on documentation review, observation, and interview, it was determined the facility failed to construct and maintain exit stair tower enclosures in one location, affecting four of four floors.

Findings include:

1. Observation on June 23, 2026, at 9:30 am, revealed the east stair tower enclosure had deficient headroom, as measured from finished floor level to overhead protrusion/obstruction (less than the required six feet, eight inches).
Exit interview with the Maintenance Manager and the Facilities Manager on June 23, 2026, at 11:00 am, confirmed the stair tower enclosure deficiency.

NFPA 101 STANDARD Discharge from Exits:

Discharge from Exits
Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface.
18.2.7, 19.2.7

Observations:
Name: BUILDING 05 - Component: 05 - Tag: 0271

Based on observation and interview, the facility failed to maintain exits in one location, affecting nine of nine smoke compartments, within this component.

Findings include:

1. Observation on July 29, 2025, at 9:15 am, revealed the basement-level, exit access corridor system had deficient headroom along much of its length due to overhead piping and wiring; headroom was less than the required six feet, eight inches in height from finished floor level.

Exit interview with the Maintenance Manager and the Facilities Manager on June 23, 2026, at 11:00 am, confirmed the exit discharge deficiencies.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)

Observations:
Name: BUILDING 05 - Component: 05 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of four floors.

Findings include:

1. Observation on June 23, 2026, at 9:33 a.m., revealed the rear door of the Generator Set Room required adjustment to fully latch within the door frame assembly.

Exit interview with the Maintenance Manager and the Facilities Manager on June 23, 2026, at 11:00 am, confirmed the hazardous area enclosure deficiency.

Plan of Correction - To be completed: 08/03/2026

Rear door of the Generator Set room was adjusted to fully latch within the door frame assembly on 07/01/2026. Perform monthly rounds for a quarter to make sure we are compliant and report out on our findings in our monthly QAPI meeting.

NFPA 101 STANDARD Corridor - Doors:

Observations:
Name: BUILDING 05 - Component: 05 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain one corridor opening, affecting one of four floors.

Findings include:

1. Observation on June 23, 2026, at 10:33 a.m., revealed the distance between the basement-level Dietary doors exceeded one-eighth-inch.

Exit interview with the Maintenance Manager and the Facilities Manager on June 23, 2026, at 11:00 am, confirmed the corridor opening deficiency.

Plan of Correction - To be completed: 08/03/2026

The distance between the basement-level Dietary doors was corrected on 07/02/2026 by using approved fire rated trim. Perform monthly rounds for a quarter to make sure we are compliant and report out on our findings in our monthly QAPI meeting.

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