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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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PHOEBE RICHLAND 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 on February 18, 2026, at Phoebe Richland 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 (AREAS A,B,C,D, E, AND F) G - Component: 01 - Tag: 0000
Facility ID# 260302

Component 01

Areas A, B, C, D, E, F and G

Based on a Medicare/Medicaid Recertification Survey completed on February 18, 2026, it was determined that Phoebe Richland Health Care Center - Areas A, B, C, D, E, F and G, was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 V (000), unprotected wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Multiple Occupancies - Construction Type:

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.

Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3

Observations:
Name: MAIN BUILDING 01 (AREAS A,B,C,D, E, AND F) G - Component: 01 - Tag: 0133 Based on observation and interview, it was determined the facility failed to maintain the fire resistance of fire barriers, affecting one of seven smoke compartments. Findings include: 1. Observation on February 18, 2026, at 11:15 a.m., revealed an open penetration surrounding a blue data cable above the ceiling tile, double fire doors near Administrators Office. Exit Interview with the Administrator and Maintenance Director on February 18, 2026, at 12:30 p.m., confirmed the fire wall penetration.

Plan of Correction - To be completed: 03/27/2026

1.The unsealed penetration will be filled with SYSTEM No. W-L-3059/ XHEZ Through penetration Firestop systems. Hllti2101531 FS-ONE MAX has been purchased to seal the open penetration that was noted on February 18th.
2. Date: Will be completed by 3/27/26.
3. Random audits of all firewalls will be conducted monthly for 3 months and any areas missing fireproofing will be reported to the EVS director and addressed promptly using the TPFS.
4. Results will be reported by the EVS Director/Designee to the QAA Committee for review and further recommendations.

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 (AREAS A,B,C,D, E, AND F) G - Component: 01 - Tag: 0161 Based on document review and interview, it was determined the facility failed to maintain the construction requirements for an unprotected wood frame building, affecting the entire building component. Findings include: 1. Document review on February 18, 2026, at 9:00 a.m., revealed Areas A, B, C, D, E, F and G were classified as a two story, Type V (000), unprotected wood frame building, that is fully sprinklered. The story height exceeds the maximum allowance for this construction type by one story. Exit Interview with the Administrator and Maintenance Director on February 18, 2026, at 12:30 p.m., confirmed story height exceeded the maximum allowance for this construction type.

Plan of Correction - To be completed: 03/27/2026

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

The TLW has been completed and emailed to Mr. Schlegel on 3/20/2026.

NFPA 101 STANDARD Means of Egress - General:

Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:
Name: MAIN BUILDING 01 (AREAS A,B,C,D, E, AND F) G - Component: 01 - Tag: 0211 Based on observations and interview, it was determined the facility failed to ensure there were no obstructions to egress, affecting one of seven smoke compartments. Findings include: 1. Observation on February 18, 2026, at 11:00 a.m., revealed a door leading to an patio could be mistaken for an exit and lacked signage indicating "Not an Exit", Gateway Living Area near Nurses Station. Exit Interview with the Administrator and Maintenance Director on February 18, 2026, at 12:30 p.m., confirmed the missing signage.

Plan of Correction - To be completed: 02/27/2026

1. Signage will be added to the door (No Exit).
2. Date of completion 2/27/26.
3. We will check all other non-emergency doors for proper signage. All missing signage will be replaced. We will conduct monthly door audits for 3 months to check for proper signage, and any missing signs will be replaced and the EVS director will be notified.
4.Results will be reported by the EVS Director/Designee to the QAA Committee for review and further recommendations.

NFPA 101 STANDARD Egress Doors:

Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4

Observations:
Name: MAIN BUILDING 01 (AREAS A,B,C,D, E, AND F) G - Component: 01 - Tag: 0222 Based on observation and interview, it was determined the facility failed to maintain emergency exit doors, affecting one of seven smoke compartments. Findings Include: 1. Observation on February 18, 2026, at 11:10 a.m., revealed the emergency exit door failed to release after 15 seconds and sound door alarm as indicated on sign posted, Glass Hallway that leads to Emergency Generator. Exit Interview with the Administrator and Maintenance Director on February 18, 2026, at 12:30 p.m., confirmed the deficient emergency door.

Plan of Correction - To be completed: 03/10/2026

1.This door has been repaired.
2. Date: 3/10/2026.
3. We will check all other emergency exit doors for proper operation to ensure they release after 15 seconds. We will conduct monthly door audits for 3 months to check for proper operation and any doors that fail to release after 15 seconds will be repaired immediate
4. Results will be reported by the EVS Director/Designee to the QAA Committee for review and further recommendations.

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: MAIN BUILDING 01 (AREAS A,B,C,D, E, AND F) G - Component: 01 - Tag: 0363 Based on observation and interview, it was determined the facility failed to ensure corridor doors were maintained to resist the passage of smoke and positively latch when tested, affecting one of seven smoke zones. Findings include: 1. Observation on February 18, 2026, at 11:45 a.m., revealed a corridor door failed to latch when tested, Laundry Housekeeping Cart Room. Exit Interview with the Administrator and Maintenance Director on February 18, 2026, at 12:30 p.m., confirmed the door failed to latch.

Plan of Correction - To be completed: 03/10/2026

1.This door has been repaired.
2. Door repairs will be completed by 3/10/2026.
3. We will check all other doors in this smoke compartment for proper operation. We will conduct monthly door audits for 3 months to check for proper operation and any doors that fail will be repaired immediately and the EVS director will be notified.
4. Results will be reported by the EVS Director/Designee to the QAA Committee for review and further recommendations.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.

Observations:
Name: MAIN BUILDING 01 (AREAS A,B,C,D, E, AND F) G - Component: 01 - Tag: 0371 Based on document review and interview, it was determined the facility failed to maintain required travel distances within smoke compartments, for fully sprinklered buildings, affecting one of seven smoke compartments. Findings include: Document review on February 18, 2026, at 9:30 a.m., revealed the Area A/Gateway travel distance was more than 200 feet in length. Exit Interview with the Administrator and Maintenance Director on February 18, 2026, at 12:30 p.m., confirmed the excessive travel distance.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

This is a less serious (but not lowest level) 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 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.

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING 01 (AREAS A,B,C,D, E, AND F) G - Component: 01 - Tag: 0918 Based on observation and interview, it was determined the facility failed to maintain the emergency generator, affecting the entire facility. Findings include: 1. Observation on February 18, 2025, at 11:20 a.m., revealed the emergency generator annunciator panel was in trouble mode, Front Lobby. Exit Interview with the Administrator and Maintenance Director on February 18, 2026, at 12:30 p.m., confirmed the generator was in trouble mode.

Plan of Correction - To be completed: 03/10/2026

1. The fuel over the "over-fill" sensor has been removed.
2. Date completed 3/10/26.
3. Our fuel delivery company has been notified that the generator fuel tank cannot be overfilled. When there is a fuel delivery the EVS Director/Designee will be notified and ensure that the tank is not overfilled.
4. Results will be reported by the EVS Director/Designee to the QAA Committee for review and further recommendations.

Initial comments:Name: BUILDING 02 (COTTAGE AREA J) - Component: 02 - Tag: 0000
Facility ID# 260302

Component 02

Cottage Area J

Based on a Medicare/Medicaid Recertification Survey completed on February 18, 2026, it was determined that Phoebe Richland Health Care Center - Cottage Area J, was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 V (111), protected wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress - General:

Observations:
Name: BUILDING 02 (COTTAGE AREA J) - Component: 02 - Tag: 0211 Based on observations and interview, it was determined the facility failed to ensure there were no obstructions to egress, affecting one door to a courtyard. Findings include: 1. Observation on February 18, 2026, at 11:50 a.m., revealed a door leading to an enclosed courtyard could be mistaken for an exit and lacked signage indicating "Not an Exit", Cottage Memory Support. Exit Interview with the Administrator and Maintenance Director on February 18, 2026, at 12:30 p.m., confirmed the missing signage.

Plan of Correction - To be completed: 02/27/2026

1. Signage has been added to the door (No Exit).
2. Date completed 2/27/2026.
3. We will check all other non-emergency doors for proper signage. All missing signage will be replaced. We will conduct monthly door audits for 3 months to check for proper signage, and any missing signs will be replaced and the EVS director will be notified.
4. Results will be reported by the EVS Director/Designee to the QAA Committee for review and further recommendations.

Initial comments:Name: BUILDING 03 (KITCHEN ADDITION AREA H) - Component: 03 - Tag: 0000
Facility ID# 260302

Component 03

Kitchen Addition Area H

Based on a Medicare/Medicaid Recertification Survey completed on February 18, 2026, it was determined that Phoebe Richland Health Care Center - Kitchen Addition Area H, was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 (111), protected noncombustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress - General:

Observations:
Name: BUILDING 03 (KITCHEN ADDITION AREA H) - Component: 03 - Tag: 0211 Based on observations and interview, it was determined the facility failed to ensure there were no obstructions to egress, affecting one door to a courtyard. Findings include: 1. Observation on February 18, 2026, at 12:00 p.m., revealed a door leading to an enclosed courtyard could be mistaken for an exit and lacked signage indicating "Not an Exit", Connector Employee Break Area. Exit Interview with the Administrator and Maintenance Director on February 18, 2026, at 12:30 p.m., confirmed the missing signage.

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