Pennsylvania Department of Health
 PARKHOUSE REHABILITATION AND NURSING CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PARKHOUSE REHABILITATION AND NURSING CENTER
Inspection Results For:

There are  48 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
PARKHOUSE REHABILITATION AND NURSING 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 conducted on June 29, 2026, at Parkhouse Rehabilitation and Nursing 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 (CENTER 1 & 2) - Component: 01 - Tag: 0000
Facility ID #133402

Component 01

Centers I and II

Based on a Medicare/Medicaid Recertification Survey conducted on June 29, 2026, it was determined that Parkhouse Rehabilitation and Nursing Center - Center 1 and II were 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 II (000), unprotected noncombustible building, with a basement, that is fully sprinklered.


 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Name: MAIN BUILDING 01 (CENTER 1 & 2) - Component: 01 - Tag: 0100 28 Pa. Code 553.3(1) GOVERNING BODY RESPONSIBILITIES Governing body responsibilities include: (1) Conforming to applicable Federal, State and local law. This REGULATION has not been met. 35 P.S. 448.808. Issuance of license. (a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met: (2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered. Based on observation, document review and interview, it was determined the following items did not conform to applicable Federal, State and local laws and regulations: Findings include: 1. Document review and observation on June 29, 2026, at 10:00 a.m., revealed the facility failed to secure plan/narrative approval by the Department of Health prior to installing a new Fire Alarm System. Exit Interview with the Administrator and Maintenance Director on June 29, 2026, at 1:00 p.m., confirmed the facility failed to obtain Department of Health Approval. 28 Pa Code 51.3. Notification (d)
 Plan of Correction - To be completed: 08/07/2026

K100 Plan approval to be submitted for the fire alarm system upgrade by DOH. A time limed waiver will be requested for this deficiency. NHA contacted Kayla -division of plan review 7/23/26 and 7/27/26- messages left at 717-787-1911 to initiate the process with plan review. The facility will submit plans approved by Upper Providence Fire Department for fire alarm system upgrade.
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 (CENTER 1 & 2) - Component: 01 - Tag: 0133 Based on observation and interview, it was determined the facility failed to maintain the fire resistance of building separation walls and openings, affecting one of three levels. Findings include: 1. Observations on June 29, 2026, revealed unsealed penetrations of fire rated common walls in the following locations: a. 10:30 a.m., fire doors separating Center/North, around data wires. Exit Interview with the Administrator and Maintenance Director on June 29, 2026, at 1:00 p.m., confirmed the unsealed penetrations. 2. Observation on June 29, 2026, at 10:50 a.m., revealed the double doors separating Healthcare/Assisted failed to close due to coordinator malfunction. Exit Interview with the Administrator and Maintenance Director on June 29, 2026, at 1:00 p.m., confirmed the common wall door deficiency.
 Plan of Correction - To be completed: 08/07/2026

The unsealed penetration above ceiling tiles (basement fire doors that separate North from Center) will be sealed according to UL system W-J-3025 using the systems approved product. Double doors coordinator to be repaired/replaced. Random audits will be completed monthly to ensure compliance.
NFPA 101 STANDARD Means of Egress - General: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.
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 (CENTER 1 & 2) - Component: 01 - Tag: 0211 Based on observation, document review and interview, it was determined the facility failed to ensure exit egress was arranged so exits were readily accessible at all times, affecting one of two levels in the component. Findings include: 1. Document review and observation on June 29, 2026, between 9:00 a.m. and 11:00 a.m., revealed the clear headroom, basement corridor, Center Building, was approximately six feet three inches, which was below the minimum requirement of six feet eight inches. Exit Interview with the Administrator and Maintenance Director on June 29, 2026, at 1:00 p.m., confirmed the basement corridor headroom. 2. Observation on June 29, 2026, at 11:20 a.m., revealed the rear courtyard emergency exit egress path had an approximately 12" x 18" section of missing concrete, creating a trip hazard along the path to the public way. Exit Interview with the Administrator and Maintenance Director on June 29, 2026, at 1:00 p.m., confirmed the egress obstruction.
 Plan of Correction - To be completed: 08/07/2026

The facility requests that the Department of Health conduct an FSES for this deficiency

The facility will obtain quotes to repair/replace the broken concrete at the rear courtyard. The facility will review to determine if the concrete can be repaired in house or if outside vendors need to install. A time limed waiver will be requested for this deficiency
NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING 01 (CENTER 1 & 2) - Component: 01 - Tag: 0345 Based on document review and interview, it was determined the facility failed to maintain Fire Alarm components, affecting the entire facility. Based on document review and interview, it was determined the facility failed to maintain Fire Alarm components, affecting the entire facility. Findings include: 1. Document review on June 29, 2026, at 9:30 am, revealed December 2025, Annual Fire Alarm Inspection Report noted 11 deficiencies, which remained uncorrected at time of survey: Exit Interview with the Administrator and Maintenance Director on June 29, 2026, at 1:00 p.m., confirmed the listed deficiencies remained uncorrected at time of survey.
 Plan of Correction - To be completed: 08/07/2026

The facility will ensure outstanding deficiencies from the Fire Alarm System Report 12/25 are corrected with the completion of the fire alarm system upgrade. The facility is in the process of upgrading the fire alarm system. Vendor to be contacted to schedule fire alarm inspection. A time limed waiver will be requested for this deficiency
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 (CENTER 1 & 2) - Component: 01 - Tag: 0353 Based on observation and interview, it was determined that the facility failed to ensure that automatic sprinkler system components are inspected and maintained at required intervals, for one of four quarters. Findings include: 1. Document review on June 29, 2026, at 9:30 a.m., revealed the facility could not produce documentation showing quarterly sprinkler inspections had been performed for the 1st and 2nd quarters of 2026. Exit Interview with the Administrator and Maintenance Director on June 29, 2026, at 1:00 p.m., confirmed the missing quarterly sprinkler inspection.
 Plan of Correction - To be completed: 08/07/2026

The facility will maintain compliance with the required Sprinkler Inspection upon the completion of the fire alarm system upgrade. The facility is in the process of upgrading the fire alarm system. Vendor contacted to inspect sprinkler system during fire alarm system upgrade. A time limed waiver will be requested for this deficiency
NFPA 101 STANDARD Fire Drills: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.
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: MAIN BUILDING 01 (CENTER 1 & 2) - Component: 01 - Tag: 0712 Based on document review and interview, it was determined the facility failed to ensure fire drills were conducted quarterly for two of twelve required drills. Findings include: 1. Document review on June 29, 2026, at 9:30 am, revealed the facility could not provide documentation that fire drills had been conducted for the following times: a. 2nd quarter 2025, 2nd shift. b. 2nd quarter 2018, 3rd shift. Exit Interview with the Administrator and Maintenance Director on June 29, 2026, at 1:00 p.m., confirmed the missing fire drills.
 Plan of Correction - To be completed: 08/07/2026

The facility will maintain compliance with required Fire Drill documentation by implementing the process for fire alarm drill documentation to be entered into the facility Tels system timely. Maintenance/Designee will initiate a task to be completed and submitted by the 25th of the month to ensure documentation is submitted timely.
NFPA 101 STANDARD Electrical Systems - Other: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.
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 (CENTER 1 & 2) - Component: 01 - Tag: 0911 Based on observation and interview, it was determined the facility failed to ensure electrical wiring and equipment was protected, affecting one of three levels. Findings include: 1. Observations on June 29, 2026, revealed electrical junction boxes missing protective cover plates in the following locations: a. 10:40 a.m., Activities storage room. b. 11:20 am, 1st floor corridor by room C-105. ~Refer to the 2011 edition of NFPA 70 - National Electrical Code, Section 314.28 (C). Exit Interview with the Administrator and Maintenance Director on June 29, 2026, at 1:00 p.m., confirmed the missing covers.
 Plan of Correction - To be completed: 08/07/2026

Junction box cover plates were replaced by activities storage room and 1st floor corridor by rm. 105. Maintenance/Designee to complete random audits monthly through the Tels system to ensure junction box cover plates are intact.
Initial comments:Name: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0000
Facility ID #133402

Component 02

North Building

 

Based on a Medicare/Medicaid Recertification Survey conducted on June 29, 2026, it was determined that Parkhouse Rehabilitation and Nursing Center - North Building 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 an eight-story, Type II (222), fire resistive building, with a basement and penthouses, 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: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0133 Based on observation and interview, it was determined the facility failed to maintain the fire resistance of fire barriers, affecting one of nine levels. Findings include: 1. Observation on June 29, 2026, at 11:45 a.m., revealed penetrations above ceiling tiles, Basement fire doors that separate the North Component from the Center Component. Exit Interview with the Administrator and Maintenance Director on June 29, 2026, at 1:00 p.m., confirmed the fire barrier penetrations.
 Plan of Correction - To be completed: 08/07/2026

The unsealed penetration above ceiling tiles (basement fire doors that separate North from Center) will be sealed according to UL system W-J-3025 using the systems approved product. Random audits will be completed monthly to ensure compliance.
NFPA 101 STANDARD Emergency Lighting: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.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0291 Based on observation and interview, it was determined the facility failed to ensure battery back-up lighting was maintained in operable condition, affecting one of nine levels. Findings include: 1. Observation on June 29, 2026, at 11:30 a.m., revealed the battery back-up lighting fixture failed to illuminate when tested, Basement CSR Room. Exit Interview with the Administrator and Maintenance Director on June 29, 2026, at 1:00 p.m., confirmed the battery backup light failed to illuminate.
 Plan of Correction - To be completed: 08/07/2026

 Battery Back Up replaced in basement. Maintenance/Designee to complete random audits monthly through the Tels system to ensure battery backups properly illuminate when tested.
NFPA 101 STANDARD Vertical Openings - Enclosure: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.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0311 Based on observation, document review and interview, it was determined the facility failed to ensure vertical openings maintain a fire resistance rating between floors, affecting the entire building component. Findings include: 1. Observation and document review on June 29, 2026, between 9:00 a.m. and 12:30 p.m., revealed electrical panel box LP 81, penetrates the building service shaft enclosure, on the eighth floor. This condition was noted throughout the component, in all electrical panel boxes, penetrating both building service shaft enclosures on all floors. Exit Interview with the Administrator and Maintenance Director on June 29, 2026, at 1:00 p.m., confirmed the vertical openings lacked a fire-resistive integrity.
 Plan of Correction - To be completed: 08/07/2026

The facility requests that the Department of Health conduct an FSES for this deficiency.
NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
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 02 (NORTH BUILDING) - Component: 02 - Tag: 0321 Based on observation and interview, it was determined the facility failed to maintain hazardous enclosures, affecting one of nine levels. Findings include: 1. Observation on June 29, 2026, at 10:15 a.m., revealed the Solarium was being used for excessive amounts of linen storage. The door lacked a self-closer. Exit Interview with the Administrator and Maintenance Director on June 29, 2026, at 1:00 p.m., confirmed the door lacked a self-closer.
 Plan of Correction - To be completed: 08/07/2026

N4 solarium excess linen was removed and self closure was installed. Maintenance/Designee to complete random audits monthly through the Tels system to ensure the solarium is kept free of excess linen storage.
NFPA 101 STANDARD Fire Alarm System - Initiation: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.
Fire Alarm System - Initiation
Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse's stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200' travel distance is not exceeded.
18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5
Observations:
Name: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0342 Based on observation and interview, it was determined the facility failed to maintain fire alarm initiating devices, affecting one of nine levels. Findings include: 1. Observation on June 29, 2026, at 10:45 a.m., revealed a smoke detector was obstructed due to a plastic cover, First Floor Electric Room. Exit Interview with the Administrator and Maintenance Director on June 29, 2026, at 1:00 p.m., confirmed the covered smoke detector.
 Plan of Correction - To be completed: 08/07/2026

Smoke detector was cleared of the plastic cover. Maintenance/Designee to complete random audits monthly through the Tels system to ensure smoke detectors clear of hazards/obstructions.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0372 Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls free of unsealed penetrations, affecting two of nine levels. Findings include: 1. Observation on June 29, 2026, between 9:55 a.m. and 11:20 a.m., revealed smoke wall penetrations at the following locations: a. 9:55 a.m., Sixth Floor double smoke doors, above ceiling near Room 619. b. 11:20 a.m., First Floor double smoke doors, above ceiling near Elevator 8. Exit Interview with the Administrator and Maintenance Director on June 29, 2026, at 1:00 p.m., confirmed the smoke wall penetrations.
 Plan of Correction - To be completed: 08/07/2026

The unsealed penetration of the smoke wall penetration N6 above 619 and 1st floor near elevator 8 will be sealed according to UL system W-J-3025 using the systems approved product. Random audits will be completed monthly to ensure compliance.
NFPA 101 STANDARD HVAC: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.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




Observations:
Name: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0521 Based on observation, document review and interview, it was determined the facility failed to ensure fire dampers were properly installed, affecting one of nine levels. Findings include: 1. Observation and document review on June 29, 2026, between 9:00 a.m. and 12:30 p.m., revealed fire dampers installed inside ductwork penetrating the building services shaft, on the fourth floor, were not installed in a sleeve or frame, secured by perimeter-mounting angles on both sides of the shaft opening. Mounting angles were only installed on the outside or habitable side of the shaft. Exit Interview with the Administrator and Maintenance Director on June 29, 2026, at 1:00 p.m., confirmed the fire damper installation was incomplete.
 Plan of Correction - To be completed: 08/07/2026

The facility requests that the Department of Health conduct an FSES for this deficiency
NFPA 101 STANDARD Electrical Systems - Other: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.
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)
Observations:
Name: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0911 Based on observation and interview, it was determined facility failed to maintain protection of electrical wiring, affecting one of nine levels. Findings include: 1. Observation on June 29, 2026, at 10:554 a.m., revealed a junction box above ceiling tiles, not securely mounted and missing its cover plate, First Floor Oxygen Storage Room near Morgue. Exit Interview with the Administrator and Maintenance Director on June 29, 2026, at 1:00 p.m., confirmed the deficient junction box.
 Plan of Correction - To be completed: 08/07/2026

Junction box was mounted and cover plate was replaced at 1st floor corridor by rm. 105. Maintenance/Designee to complete random audits monthly through the Tels system to ensure junction box cover plates are intact.
NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
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 02 (NORTH BUILDING) - Component: 02 - Tag: 0923 Based on observation and interview, it was determined the facility failed to maintain storage of oxygen cylinders, affecting one of nine levels. Findings include: 1. Observation on June 29, 2026, at 9:30 a.m., revealed the door could not be opened due to broken door hardware and a non-working key code reader, Eighth Floor Oxygen Storage Room. Exit Interview with the Administrator and Maintenance Director on June 29, 2026, at 1:00 p.m., confirmed the Oxygen Storage Room could not be accessed.
 Plan of Correction - To be completed: 08/07/2026

N8 O2 room door was repaired. Maintenance/Designee to complete random audits monthly through the Tels system to ensure doors properly open/close.
Initial comments:Name: BUILDING 03 (WEST BUILDING) - Component: 03 - Tag: 0000
Facility ID #133402

Component 03

West Building

Based on a Medicare/Medicaid Recertification Survey conducted on June 29, 2026, it was determined that Parkhouse Nursing and Rehabilitation Center - West Building 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 three-story, Type II (000), unprotected noncombustible building, with a basement, that is fully sprinklered.


 Plan of Correction:


NFPA 101 STANDARD Exit Signage: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.
Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)
Observations:
Name: BUILDING 03 (WEST BUILDING) - Component: 03 - Tag: 0293 Based on observation and interview, it was determined the facility failed to provide proper egress signage in accordance with NFPA 101, affecting one of four levels within the facility Findings include: Observation on June 29, 2026, at 10:05 a.m., revealed a missing "Exit" sign over the first-floor stairwell door leaving first-floor center stairwell.Observation on June 29, 2026, at 10:06 a.m., revealed a missing "Not an Exit" sign on first-floor stairwell's back door.Exit Interview with the Administrator and Maintenance Director on June 29, 2026, at 1:00 p.m.,confirmed the missing egress signage.
 Plan of Correction - To be completed: 08/07/2026

Exit signage was provided on the 1st floor exit stairwell and a Not an exit sign was provided to the back door. Maintenance/Designee to complete random audits monthly through the Tels system to ensure means of egress properly labeled.
NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
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 03 (WEST BUILDING) - Component: 03 - Tag: 0321 Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures on one of four levels within the facility. Findings include: 1. Observation on June 29, 2026, between 9:00 a.m., and 12:30 p.m. revealed: a) Third floor soiled room had a hole remaining in ceiling where a smoke detector was recently relocated from. b) Third floor soiled room door across from nurse's station failed to latch when tested. Exit Interview with the Administrator and Maintenance Director on June 29, 2026, at 1:00 p.m., confirmed the above deficiencies.
 Plan of Correction - To be completed: 08/07/2026

The unsealed penetration of the W3 soiled room will be sealed according to UL system W-J-3025 using the systems approved product. The door to the soiled room was repaired. Random audits will be completed monthly to ensure compliance.
NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: BUILDING 03 (WEST BUILDING) - Component: 03 - Tag: 0345 Based on observation and interview, it was determined the facility failed to maintain fire alarm system components in operable condition, affecting one of four levels within the facility. Findings include: 1. Observation on June 29, 2026, between 9:00 a.m. and 12:30 p.m., revealed a single fire alarm smoke detector with a plastic cover, inside the first-floor high density file room, Exit Interview with the Administrator and Maintenance Director on June 29, 2026, at 1:00 p.m.,confirmed the cover over top of the smoke detector.
 Plan of Correction - To be completed: 08/07/2026

Smoke detector was cleared of the plastic cover. Maintenance/Designee to complete random audits monthly through the Tels system to ensure smoke detectors clear of hazards/obstructions.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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: BUILDING 03 (WEST BUILDING) - Component: 03 - Tag: 0353 Based on observation and interview it was determined the facility failed to ensure the automatic sprinkler system and its components were maintained, affecting the entire facility. Findings include: 1. Observation made on June 29, 2026 between 9:00 a.m., and 12:30 p.m., revealed: a) Inside the first-floor kitchen, the sprinkler dry valve assembly had a gauge dated 2020. b) Basement fire pump controller had a gauge dated 2019. Exit Interview with the Administrator and Maintenance Director on June 29, 2026, at 1:00 p.m.,confirmed the sprinkler gauges were out of their five-year calibration compliance.
 Plan of Correction - To be completed: 08/07/2026

Kitchen sprinkler dry valve dated 2019 will be replaced to maintain 5 year compliance. Maintenance/Designee to complete random audits monthly through the Tels system to ensure valve replacement within the 5 years compliance.
NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
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 (WEST BUILDING) - Component: 03 - Tag: 0923 Based on observation and interview, it was determined the facility failed to maintain oxygen cylinder storage, affecting two of four levels within the facility. Findings include: 1. Observations on June 29, 2026, revealed: a) 10:25 a.m., second floor "center" oxygen room lacked a door closure, oxygen cylinders were mixed between "full" and "empty" and cylinders were stored within five feet from an electrical power outlet. b) 11:10 a.m., first floor oxygen room lacked a door closure, and oxygen cylinders were stored within five feet from an electrical power outlet. Exit Interview with the Administrator and Maintenance Director on June 29, 2026, at 1:00 p.m., confirmed the cylinder storage deficiencies.
 Plan of Correction - To be completed: 08/07/2026

W2 O2 room door closure was installed and O2 empty and full bottles were separated and not stored within 5ft of electrical power outlet. Maintenance/Designee to complete random audits monthly through the Tels system to ensure compliance.

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