Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Phoebe Allentown Health Care Center during CMS and state inspections, most recent first.
Failure to document PRN psychotropic review: A resident with Alzheimer's disease, dementia, and anxiety disorder received PRN Lorazepam gel for anxiety, but the MAR showed repeated use without documented physician re-evaluation of the continued need and without a stop date after 14 days. The Administrator confirmed the medication had not been re-evaluated and no stop date had been ordered.
Inaccurate MDS assessments failed to reflect the current status of two residents. One resident’s MDS did not show hospice services in Section O despite a terminal Alzheimer’s-related diagnosis and hospice care, and another resident’s annual MDS did not list PTSD in Section I even though the care plan and psychosocial assessment documented the diagnosis and childhood trauma.
A resident with obstructive sleep apnea had a physician order for nightly CPAP use, and the TAR showed the device was used every night. However, there was no documented evidence that CPAP use was included in the current care plan, and the ADON confirmed it was not addressed.
Physician orders were not carried out for three residents. One resident with vascular dementia, CKD, and dysphagia had weight loss and a physician-ordered SLP assessment for chewing difficulty that was not documented as completed. Another resident with spinal stenosis and cognitive impairment was ordered Geri sleeves for arm protection, but observations showed the sleeves were not in place and there were no refusals documented. A third resident with Alzheimer's disease and ankle swelling was ordered tubigrips to both legs, but repeated observations showed the tubigrips were not applied and no refusals were documented.
False documentation and missed PICC dressing change. A resident with DM, HTN, and sepsis had a PICC for IV antibiotics, with orders for regular dressing changes and facility policy requiring timely documentation of catheter details and dressing care. Observations showed the PICC dressing remained dated from the resident’s hospital stay, the resident said it had not been changed since before admission, and an LPN documented a dressing change that did not occur; the ADON confirmed the documentation was false.
Failure to obtain post-dialysis summaries for a resident receiving dialysis. A resident with ESRD and dependence on renal dialysis had orders for dialysis 3 times weekly and for staff to ensure the post-dialysis summary was returned after each session or to contact the dialysis center if it was not returned. Record review found no evidence that the summary was obtained on 35 of 56 occasions, and the Administrator confirmed there was no documented evidence that staff ensured the form was returned or contacted the dialysis center when it was missing.
Failure to follow infection control policy occurred when an RN did not wear a gown during wound care for a resident with a stage 4 sacral pressure injury. The resident had vascular dementia and peripheral vascular disease, and the Assistant DON confirmed that appropriate PPE was not used during the dressing change.
A resident with dementia and feeding difficulties, who required assistance with eating and was on a pureed diet, was served a meal in bed without utensils. The resident was observed attempting to eat the pureed food with his fingers, experiencing difficulty and unable to complete the meal in a dignified manner.
Two residents with hemiplegia and contractures did not have their prescribed hand or forearm splints applied as ordered by physicians and recommended by therapy, despite care plans indicating the need for these interventions. Observations showed the splints were not in use during multiple checks, and the DON confirmed they should have been applied.
A resident with dementia, anxiety, and a history of falls, who was identified as cognitively impaired and at risk for falls, experienced six falls over five months due to inadequate supervision. The resident's impulsive behaviors and repeated incidents, including falls from bed and chairs resulting in injury and hospital evaluation, indicate that staff did not provide sufficient oversight to prevent accidents.
A resident with muscle weakness and a history of stroke, who was incontinent and required two staff for transfers, waited approximately 27 minutes for staff to respond to her call bell after requesting assistance to be changed. The facility's expected response time for call bells was ten minutes or less, but the call bell remained unanswered for nearly half an hour, as confirmed by device records and staff interviews.
Two residents did not receive physician-ordered medications and wound care treatments as prescribed, with no documentation of administration or refusal. The DON confirmed that staff failed to document whether the medications and treatments were offered or provided on the specified dates.
The facility failed to properly store and label food items, leading to unsanitary conditions in the dietary department and unit pantries. Surveyors found expired and unlabeled food in the main kitchen and unit pantries, contrary to facility policy. The Culinary Services Manager acknowledged the oversight.
A resident with a history of stroke and muscle weakness, who was alert and oriented but dependent on staff for transfers, had a care plan indicating a preference to be out of bed by 9:00 a.m. Observations showed the resident remained in bed past this time on multiple occasions. The resident expressed a preference to be out of bed by 10:00 a.m. at the latest, which was not being met. The DON confirmed the resident's preference, highlighting the facility's failure to honor it.
The facility failed to develop comprehensive care plans for two residents. One resident with diabetes and chronic kidney disease lacked interventions for urinary incontinence in her care plan, despite being incontinent and on diuretics. Another resident with anxiety and depression had no documented interventions for psychotropic drug use, despite receiving antipsychotic and antidepressant medications. These deficiencies were confirmed by facility staff.
The facility failed to provide scheduled morning activities for several residents, leading to expressions of boredom and restlessness. Residents with various diagnoses, including dementia and Parkinson's disease, were observed without activities on the [NAME] Way nursing unit. Their care plans highlighted the importance of engaging in activities, yet the absence of scheduled activities on a specific day resulted in unmet needs.
A facility failed to follow a physician's order for a resident with congestive heart failure and hypertension, which required daily weight monitoring and provider notification for significant weight gain. There was no evidence of weight being obtained or refusal documented on several dates, as confirmed by the DON.
A facility failed to implement interventions to prevent further decline in a resident's range of motion. The resident, with a history of stroke and muscle weakness, was dependent on staff for care and had a physician's order for a right elbow splint. Observations showed the splint was not applied, and the resident reported difficulty in receiving assistance from staff, with only one nurse trained to apply the splint. The DON confirmed the staff's responsibility to apply the splint as ordered.
Failure to Document Re-evaluation and Stop Date for PRN Anti-Anxiety Medication
Penalty
Summary
The facility failed to document the rationale for the continued use of a PRN anti-anxiety medication for one sampled resident who was receiving psychotropic medications. Resident 40 had diagnoses including Alzheimer's disease, dementia, and an anxiety disorder, and the MDS indicated cognitive impairment. The care plan noted that the resident received Lorazepam for anxiety. A physician ordered Lorazepam gel to be applied topically every two hours as needed for anxiety and to re-evaluate the need to continue the PRN medication on May 14, 2026. The May 2026 MAR showed the PRN Lorazepam was applied six times during the month, but there was no documented evidence that the physician evaluated the continued use of the medication, and there was no stop date indicated after 14 days for the PRN medication. In interview, the Administrator stated that the PRN medication had not been re-evaluated by the physician and there was no stop date after 14 days ordered.
Inaccurate MDS Assessments
Penalty
Summary
The facility failed to ensure that MDS assessments were completed accurately to reflect residents’ current status for two sampled residents. One resident had Alzheimer’s disease, and the care plan identified a terminal diagnosis related to Alzheimer’s disease with hospice services starting on May 22, 2026; however, the significant change MDS failed to indicate in Section O that the resident was receiving hospice services. Another resident had dementia, anxiety, and PTSD, and the care plan and psychosocial assessment documented PTSD and family-reported childhood trauma; however, the annual MDS failed to reflect PTSD in Section I for active diagnoses. During an interview on June 11, 2026, the Administrator stated that the MDS assessments had not accurately reflected the residents’ current medical status.
Care Plan Did Not Address CPAP Use
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed Resident 18’s needs as identified in the comprehensive assessment. Resident 18 had diagnoses including obstructive sleep apnea, and the MDS dated May 27, 2026 indicated the resident received a respiratory treatment from a non-invasive mechanical ventilator. A physician’s order dated December 3, 2025 directed staff to apply the CPAP device every night, and the TAR from December 2025 through June 2026 showed the resident used the CPAP device every night. However, there was no documented evidence that CPAP use was included in the resident’s current care plan. During an interview on June 11, 2026, the Assistant DON confirmed that CPAP was not addressed on the current care plan.
Physician Orders Not Implemented for Three Residents
Penalty
Summary
The facility failed to ensure physicians' orders were implemented for three residents. Resident 14 had vascular dementia, chronic kidney disease, and dysphagia, and the record showed unplanned weight loss. A dietary note dated May 11, 2026, stated the resident had lost four additional pounds over the prior month, that intake did not appear to meet needs as evidenced by weight loss, and recommended assessment by speech therapy related to chewing difficulty. On May 24, 2026, the physician ordered a speech therapy assessment for the resident's reported chewing difficulties, but there was no documented evidence that Speech Therapy completed the assessment. The Assistant DON confirmed on June 12, 2026, that Resident 14 was not assessed by speech therapy as ordered. Resident 18 had spinal stenosis and abnormal posture, with cognitive impairment and dependence on staff for upper body dressing. The care plan identified risk for bruises, skin tears, and skin breakdown and included a goal for staff to apply Geri sleeves or encourage long-sleeved clothing for prevention. A physician ordered Geri sleeves for the resident's arms on March 12, 2026, but observations on June 9 and June 11, 2026, showed the resident wearing short-sleeved shirts with both arms exposed and the Geri sleeves not in place. The Assistant DON confirmed there was no documentation that the Geri sleeves were offered and no refusals noted. Resident 204 had Alzheimer's disease, dementia, high blood pressure, and ankle swelling, and was dependent on staff for both upper and lower body dressing. A physician ordered tubigrips to both lower extremities in August 2025 for ankle swelling, but observations on June 9, June 10, and June 11, 2026, showed the resident without the tubigrips in place. The Assistant DON confirmed staff did not apply the tubigrips and there were no documented refusals.
False Documentation and Missed PICC Dressing Change
Penalty
Summary
The facility failed to implement appropriate measures for the care and management of a PICC line for one resident with diabetes mellitus, high blood pressure, and sepsis of the right foot wound who was admitted with the PICC in place for IV antibiotics. Facility policy required documentation of the catheter type, length, lot number, and arm circumference on admission, and required the initial dressing change within 24 hours and then every seven days or more often as needed. A physician order directed the central venous catheter dressing to be changed every five days and as needed. Observations on June 9, June 10, and June 11 showed the PICC line in the resident’s right upper arm covered with a dressing dated June 3. The resident stated the dressing had not been changed since the hospital before admission. The MAR showed an LPN documented that the dressing change was completed on June 8, but there was no evidence the resident refused the dressing change. An LPN confirmed the dressing was still dated June 3 and had not been changed, and the ADON confirmed the nurse falsely documented that the dressing change had been completed on June 8 while the actual dressing remained dated June 3.
Failure to Obtain Post-Dialysis Summaries
Penalty
Summary
The facility failed to provide ongoing assessment and monitoring for a resident receiving dialysis. Resident 18 had diagnoses including end-stage renal disease and dependence on renal dialysis, and the physician ordered dialysis every Monday, Wednesday, and Friday. The physician also ordered staff to ensure the post-dialysis summary was returned with the resident after each dialysis session, and if it was not returned, licensed staff were to contact the dialysis center to obtain the information every day shift on Monday, Wednesday, and Friday. Clinical record review found no evidence that staff obtained the post-dialysis summary information on 35 of 56 occasions between February 1, 2026, and June 10, 2026. During interview, the Administrator confirmed there was no documented evidence that staff ensured the completed post-dialysis summary was returned or contacted the dialysis center when the form was not returned after each dialysis session.
Infection Control PPE Not Used During Wound Care
Penalty
Summary
Failure to provide and implement an infection prevention and control program was identified when staff did not follow the facility’s Transmission Based Precautions policy during wound care for Resident 111. The policy, last reviewed August 19, 2025, required a gown and gloves for any high-contact resident care activity, including wound care. Resident 111 had diagnoses of high blood pressure, vascular dementia, and peripheral vascular disease, and had a stage four pressure injury on the sacrum documented on June 2, 2026. A physician’s order dated June 8, 2026, directed staff to apply gauze soaked with Vashe wound solution to the wound base, lightly pack the wound bed with Kerlix, and cover with a dry dressing twice daily. During observation of wound care on June 10, 2026, at 10:30 a.m., RN 1 did not wear a gown during the dressing change. At 11:45 a.m. the same day, the Assistant DON confirmed that staff did not use appropriate PPE during Resident 111’s dressing change.
Failure to Provide Utensils Compromises Resident Dignity During Meal
Penalty
Summary
Staff failed to provide care and services in a manner that maintained a resident's dignity. Clinical record review showed that the resident had dementia with mood disturbance, feeding difficulties, was cognitively impaired, and required assistance with self-care, including eating. The care plan indicated the resident was at nutritional risk, required a mechanically altered diet, and was to receive pureed food with double portions. During observation, staff delivered the resident's lunch meal to his room while he was in bed, but did not provide any utensils on the tray. The resident attempted to eat his pureed meal, including mashed potatoes, with his fingers from the time the meal was served until the observation ended. The resident was observed having difficulty eating with his fingers and was unable to complete his meal in a dignified manner.
Failure to Apply Prescribed Splints for Residents with Limited Range of Motion
Penalty
Summary
The facility failed to provide services and treatment to prevent further limitations in range of motion (ROM) for two residents with existing ROM limitations. Both residents had a history of stroke with hemiplegia affecting the non-dominant left side and were assessed as having limitations in ROM on one side of both upper and lower extremities. Care plans indicated the need for assistance with activities of daily living (ADLs), and occupational therapy discharge summaries recommended the use of hand or forearm splints. Physician orders specified that splints were to be applied continuously or daily, with regular checks for skin integrity. Despite these orders and care plan interventions, multiple observations revealed that both residents were not wearing their prescribed splints during various times of the day, both while in bed and seated in their wheelchairs. In one case, the splint was observed on the nightstand rather than on the resident. The Director of Nursing confirmed that the splints were to be applied as ordered for both residents, indicating that the facility did not follow physician orders and therapy recommendations to maintain or improve ROM.
Failure to Provide Adequate Supervision for Fall Prevention
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for a resident with dementia, mood disorder, anxiety, and a history of falling. Clinical records indicated that the resident was cognitively impaired, had impulsive behaviors, and was identified as being at risk for falls in both the care plan and fall risk assessments. Despite these documented risks, the resident experienced six falls over a five-month period, including multiple incidents of falling out of bed and out of chairs in various areas of the facility. Some of these falls resulted in injuries, such as a lump on the forehead, and one incident required hospital evaluation. The repeated falls demonstrate that staff did not provide sufficient supervision or interventions to prevent accidents for this high-risk resident.
Delayed Call Bell Response for Dependent Resident
Penalty
Summary
A resident with a history of muscle weakness and stroke, who was incontinent and required assistance from two staff members for transfers, experienced a significant delay in response to her call bell. On the observed date, the resident activated her call bell at 10:51 a.m. and it remained unanswered until 11:21 a.m., as confirmed by the Device Activity Report. During this period, the resident reported waiting approximately 20 minutes for assistance to be changed, and stated that extended wait times for call bell responses were a frequent occurrence. Staff did not enter the room to provide the requested assistance until 27 minutes after the call bell was activated. The DON confirmed that the facility's expected response time for call bells was ten minutes or less.
Failure to Administer and Document Physician-Ordered Medications and Treatments
Penalty
Summary
Staff failed to implement physician's orders for two residents. For one resident with dementia and anxiety, clinical records showed that morphine sulfate and haloperidol were not administered as ordered on multiple occasions, with no documentation of administration or resident refusal. Specifically, morphine was not given at 9:00 a.m. or 1:00 p.m. on one date, and haloperidol was not given at 9:00 a.m. on the same date and at 6:00 a.m. on another date. There was no evidence in the clinical record that the resident had refused these medications. For another resident with peripheral vascular disease, chronic kidney disease, and congestive heart failure, staff did not document the application of a prescribed wound care treatment on two separate dates. The physician's order required daily cleansing and dressing of a right wrist wound, but there was no evidence in the clinical record that the treatment was provided or refused by the resident. The DON confirmed that staff should have documented administration or refusal of medications and treatments, and that there was no such documentation for the identified dates.
Improper Food Storage and Labeling in Dietary Department
Penalty
Summary
The facility failed to adhere to its policies regarding the proper storage and labeling of food items, leading to unsanitary conditions in the dietary department and unit pantries. During a tour of the main kitchen, surveyors observed several violations, including an opened container of icing with an expired use-by date, improperly labeled raw pork loins, and an open container of coleslaw with an expired use-by date. Additionally, there was an opened bag of croissants without a date, and ice build-up was found on several opened boxes of food items in the walk-in freezer. In the unit kitchens, opened packages of whipped topping and a plated Danish were found without proper labeling. Further observations in the unit pantries revealed that food items were not labeled with residents' names or dates, contrary to facility policy. In the 2 East unit pantry, several opened food items, including a package of dates, a bottle of coffee creamer, shredded cheese, and a jar labeled as sour cherry and honey preserves, were found without proper labeling. Similarly, in the 3 East unit pantry, four sandwiches were found without any resident identification or date. The Culinary Services Manager acknowledged that these items should have been dated and legible, indicating a lapse in following established procedures.
Failure to Honor Resident's Preference for Out-of-Bed Time
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not adhering to the resident's preference to be out of bed by 9:00 a.m. The clinical record review indicated that the resident, who had a history of a stroke with residual right-sided weakness and muscle weakness, was alert and oriented but dependent on staff for transfers. The care plan specified that the resident preferred to be out of bed by 9:00 a.m. daily. However, observations on two consecutive days showed that the resident remained in bed past the preferred time. During an interview, the resident expressed a preference to be out of bed by 10:00 a.m. at the latest, but noted that this was not being met. The Director of Nursing confirmed the resident's preference to be out of bed by 9:00 a.m., acknowledging the failure to meet this preference.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents, as identified during a clinical record review and staff interviews. Resident 33, who was admitted with diagnoses including diabetes and chronic kidney disease, was noted in the Minimum Data Set (MDS) Care Area Assessment (CAA) summary to have urinary incontinence that needed to be addressed in her care plan. Despite being always incontinent of urine and continuing the use of prescribed diuretics, there was no documented evidence of interventions for her incontinence in the current care plan. This was confirmed by the Director of Nursing during an interview. Similarly, Resident 231, admitted with anxiety and depression, was identified in the MDS CAA summary as requiring interventions for psychotropic drug use in the care plan. The medication administration record showed that the resident was receiving both an antipsychotic and an antidepressant, yet there was no documented evidence of interventions for managing the psychotropic drug use in the care plan. This deficiency was confirmed by the Administrator during an interview.
Failure to Provide Scheduled Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing activity program to meet the needs of five residents, as observed during a survey. The activities calendar for the week of August 5 through August 11, 2024, showed a lack of scheduled morning activities on the [NAME] Way nursing unit, particularly on August 7, 2024. Residents 20, 21, 107, 144, and 193 were observed in the lounge area during the morning hours without any scheduled activities, leading to expressions of boredom and restlessness. These residents had various diagnoses, including dementia, anxiety, depression, chronic kidney disease, congestive heart failure, and Parkinson's disease, and their care plans indicated the importance of engaging in activities. Resident 20, who had dementia, anxiety, and depression, expressed a need for cueing and setup to engage in activities, while Resident 21, with chronic kidney disease and depression, required assistance with activities and social interaction. Resident 107, with anxiety and Parkinson's disease, was independent in choosing leisure pursuits but was aware of the lack of morning activities. Resident 144, with dementia and Parkinson's disease, expressed that activities were repetitious, and Resident 193, with Alzheimer's dementia, was restless and repeatedly checked for activities. The absence of scheduled activities on August 7, 2024, led to these residents experiencing boredom and a lack of engagement, as confirmed by the administrator's acknowledgment of no scheduled morning activity on that day.
Failure to Implement Physician's Orders for Daily Weight Monitoring
Penalty
Summary
The facility failed to implement a physician's order for a resident diagnosed with congestive heart failure and hypertension. The order, dated April 19, 2024, required staff to obtain the resident's daily weight and notify the provider if there was a weight gain of three or more pounds in one day. However, there was no evidence that the resident's weight was obtained, nor was there documentation of the resident refusing to be weighed on multiple dates in June, July, and August 2024. This deficiency was confirmed during an interview with the Director of Nursing on August 8, 2024.
Failure to Implement ROM Interventions for Resident
Penalty
Summary
The facility failed to implement interventions to prevent further decline and/or improve range of motion for a resident with limited range of motion. Resident 40, who had a history of a stroke with residual right-sided weakness and muscle weakness, was dependent on staff for all upper and lower body care. A physician's order required the application of a splint to the resident's right elbow daily. However, observations on multiple occasions revealed that the splint was not in place, and the resident expressed that she wanted to wear the splint but had to wait for staff assistance. She reported asking for help multiple times without receiving it, and only one nurse was trained to apply the splint. The Director of Nursing confirmed that staff was supposed to apply the splint as ordered.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Allentown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jewel Healthcare And Rehabilitation Center | 0.5 mi | ★★★★★ | 2 | 0 |
| St Luke's Hospital Sacred Heart Campus Tcf | 1.8 mi | — | 0 | 0 |
| Good Shepherd Home Raker Center | 1.8 mi | ★★★★★ | 4 | 0 |
| Cedar Crest Post Acute | 2.5 mi | ★★★★★ | 13 | 0 |
| Cedarbrook Senior Care And Rehabilitation | 2.7 mi | ★★★★★ | 8 | 0 |
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