Pennsylvania Department of Health
PARKHOUSE REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

PARKHOUSE REHABILITATION AND NURSING CENTER
Inspection Results For:

There are 159 surveys for this facility. Please select a date to view the survey results.

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PARKHOUSE REHABILITATION AND NURSING CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Findings of an Abbreviated Complaint Survey completed on March 4, 2026, at Parkhouse Rehabilitation and Nursing Center, identified deficient practice, related to the reported complaint allegations, under the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.

Plan of Correction:

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.

§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Observations:

Based on policy review, resident and staff interviews and review of resident records it was determined that the facility failed to provide assistance with activities of daily living for 1 of seventeen residents reviewed (Resident 1).

Findings include:

Facility policy titled Activities of Daily Living (ADLs), last reviewed December 2024, notes it is the policy of the facility to understand the principals of quality of life, and honor and support these principals for each resident, and that the care and services provided are person centered, and honor and support each resident's preferences, choices, values and beliefs. The facility will provide care and services for hygiene-bathing, dressing, grooming and oral care.

Review of Resident 1's February 20, 2026, Activities of Daily Living (ADLs), Admission Minimum Data Set (MDS), revealed the resident utilizes a wheelchair and requires supervision or touching assistance with showering/bathing, and requires supervision and touching assistance with tub/shower transfers.

Interview with Resident 1 on March 3, 2026, at 2:30 p.m., when the resident stated he/she had not received his/her scheduled shower on Monday March 2, 2026, or Tuesday March 3, 2026, because staff told him/her there were not enough staff scheduled on the unit to provide the care.

During the interview Resident 1 stated that he/she would like to have a shower and requested the staff be made aware.

Interview conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on March 4, 2026, at 12:55 p.m., when the above information was presented the NHA and DON stated residents often refuse showers, prefer bed baths instead, and some are care planned for bed baths only. They did not confirm Resident 1 preferred or was care planned for bed baths only.

28 Pa. Code 211.5(f) Clinical Records

28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Plan of Correction - To be completed: 03/24/2026

Resident 1 follow up for shower preference.
Resident shower schedules reviewed for preference.
Nursing staff educated on ADL policy.
Random weekly audit to confirm he/she was provided a shower/bed bath per preference for 4 weeks and review results of audit in QAPI.

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on policy review, interviews and record reviews it was determined that the facility failed to properly administer medications for 1 out of five residents reviewed (Resident 5).

Findings include:

Review of facility policy and guidelines titled Administering Medications, last revised on April 17, 2024, documents medications shall be administered in a safe and timely manner and as prescribed.

Per the policy, if a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's attending physician or medical director to discuss concerns.

Additionally, the individual administering the medication must check the label to verify the right medication, right dosage, right time, and right method of administration before giving the medication.

Review of Resident 5's care plan revealed medical diagnosis' that included Metabolic Encephalopathy (a change in how the brain works due to an underlying condition causing memory loss or confusion), Hypertension (high blood pressure), Hyperlipidemia (high level of fats in blood), Paroxysmal Atrial Fibrillation (sudden irregular heart rhythm), and Neurocognitive Disorder with Lewy Bodies (progressive brain disorder characterized by cognitive decline, movement difficulty and visual hallucinations).

Review of Resident 5's census form revealed an admission date of December 31, 2025.

Review of Resdient 5's progress notes revealed a nursing note on January 1, 2026 at 2:38 a.m. stating "this nurse notified the RN Supervisor of resident receiving insulin. New orders received to monitor blood sugars."

Review of Resident 5's medication error report revealed Resident 5 was given Humalog (fast acting insulin) instead of tuberculin solution (used to test for tuberculosis).

Review of Resdient 5's physician orders revealed there was no order for Humalog insulin.
Interview with the Director of Nursing on March 4, 2026, at 12:55 p.m.,confirmed Resident 5 received Humalog insulin instead of tuberculin solution in error on January 1, 2026.

28 PA Code 109.65 (b) Recording of drug administration

28 PA Code 211.12. (d)(1) Nursing services

28 Pa. Code 211.5(f) Clinical Records

Plan of Correction - To be completed: 03/24/2026

Resident 5 has been discharged and nurse was educated upon identification of medication administration error.
House wide audit completed for all new admissions on 1/2/26 to ensure no new admissions received insulin instead of PPD solution.
PPD solution kept in nursing office.
Licensed Nursing educated on Medication Administration Policy
Random weekly audit to ensure that resident medications are administered per orders for 4 weeks then monthly for 3 months. Results reviewed in QAPI.

483.90(i) REQUIREMENT Safe/Functional/Sanitary/Comfortable Environ:

§483.90(i) Other Environmental Conditions
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

Observations:

Based on observations it was revealed that the facility failed to provide a safe, sanitary and comfortable environment for residents, staff and the public for 2 of 8 units observed. (north building floor 7 and 8)

Findings include:

Observations made on March 3, 2026, at 2:15 p.m., of the North Building 8th floor (N8) bathroom revealed used briefs on the trash can, paper towels, used gloves, and empty bottles of body wash and shampoo in the sinks.

Observations of the N8 trash chute closet revealed trash overflowing in the bin with papers, used gloves, paper towels, and food on the floor.

Observations of the North Building stairwell revealed used gloves on the landing between floors North Building 7th floor (N7) and N8.

Observations made on March 4, 2025, at 10:05 a.m., of trash chute rooms on all floors of the North Building revealed food, used gloves and papers and paper towels on the floor on N8.

Interview conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on March 4, 2026, at 12:55 p.m., when the above information was presented the NHA and DON stated they would investigate the matter.

28 Pa. Code: 207.2(a) Administrator's responsibility.

28 Pa. Code: 201.29(k) Resident rights.

Plan of Correction - To be completed: 03/24/2026

N8 bathroom and trash closet immediately cleaned. Trash immediately cleaned from between 7 and 8 in North Tower stairwell. Audit of North Tower bathrooms, trash rooms and stairwells in North tower. Housekeeping employees educated on cleaning procedures. Random audit rooms/areas in North Tower for cleanliness weekly for 4 weeks and review results of audit in QAPI.

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