Pennsylvania Department of Health
HIGHLAND VIEW REHABILITATION & HEALTHCARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

HIGHLAND VIEW REHABILITATION & HEALTHCARE CENTER
Inspection Results For:

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HIGHLAND VIEW REHABILITATION & HEALTHCARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Follow-up Survey completed on April 14, 2025, it was determined that Highland View Rehabilitation and Healthcare Center corrected the federal deficiencies cited during the survey of February 21, 2025, under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities; however was not in compliance with the following requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on review of the facility staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one Nurse Aide (NA) per 10 residents for the day shift for one of 15 days reviewed (4/02/25); failed to ensure a minimum of one NA per 11 residents for the evening shift for one of 15 days reviewed (3/30/25); and failed to ensure a minimum of one NA per 15 residents for the overnight shift for three of 15 days reviewed (3/30/25, 4/05/25, and 4/06/25).

Findings include:

Review of facility nursing staffing documents for the time period from 3/26/25 through 4/09/25, revealed the following NA staffing shortage for the day shift where the NA ratios were not met:

4/02/25census of 41 residents3.73 NA worked and 4.10 were required

Review of facility nursing staffing documents for the time period from 3/26/25 through 4/09/25, revealed the following NA staffing shortage for the evening shift where the NA ratios were not met:

3/30/25 census of 39 residents 3.40 NA worked and 3.55 were required

Review of facility nursing staffing documents for the time period from 3/26/25 through 4/09/25, revealed the following NA staffing shortages for the overnight shift where the NA ratios were not met:

3/30/25census of 39 residents2.47 NA worked and 2.60 were required
4/05/25census of 36 residents2.20 NA worked and 2.40 were required
4/06/25census of 36 residents2.20 NA worked ans 2.40 were required

During an interview on 4/14/25, at 2:08 p.m. the Nursing Home Administrator confirmed the NA ratios were not met for the above days and shifts.

Plan of Correction - To be completed: 05/15/2025

*No residents were found to be negatively affected by failing to meet the nurse aide ratios

*Residents will be visually monitored each shift by the RN supervisor to ensure the residents are receiving quality care

*Scheduler, RN Supervisors, Director of Nursing and Assistant Director of Nursing will be educated on the proper Nurse Aide ratios for each shift

*Daily staffing sheets and the biweekly schedule will be reviewed by the Administrator, Director of Nursing, and Scheduler Monday-Friday to assure that proper nurse aide ratios are being met. This is an ongoing process that has no end date.

*Job ads are posted on Indeed and active hiring is occurring.

*Admin nursing and scheduler who is a nurse aide fill in for open shifts when call-offs occur. Nurse aides who are currently working are asked to stay into another shift and those who are not on the schedule are called to come in.

*Staff who call off are given progressive discipline so they understand the importance of calling off for their scheduled shifts.

*Staffing ratios will be reviewed at Quality Assurance Process Improvement meetings

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on review of facility nursing staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one Licensed Practical Nurse (LPN) per 40 residents for the overnight shift for two of 21 days reviewed (4/04/25 and 4/06/25).

Findings include:

Review of facility nursing staffing documents for the time period from 3/26/25 through 4/09/25, revealed the following LPN staffing shortages for the overnight shift where the LPN ratios were not met:

4/04/25census of 36 residents0.16 LPNs worked and 1.00 were required
4/06/25census of 36 residents0.88 LPNs worked and 1.00 were required

During an interview on 4/14/25, at 2:08 p.m. the Nursing Home Administrator confirmed the LPN ratios were not met for the above days and shift.

Plan of Correction - To be completed: 05/15/2025

*No residents were found to be negatively affected by failing to meet the licensed practical nurse ratios

*Residents will be visually monitored each shift by the RN supervisor to ensure the residents are receiving quality care

*Scheduler, RN Supervisors, Director of Nursing and Assistant Director of Nursing will be educated on the proper licensed practical nurse ratios for each shift

*Daily staffing sheets and the biweekly schedule will be reviewed by the Administrator, Director of Nursing, and Scheduler Monday-Friday to assure that proper nurse aide ratios are being met. This is an ongoing process that has no end date.

*Job ads are posted on Indeed and active hiring is occurring.

*Admin nursing fill in for open shifts when call-offs occur. Licensed practical nurses and registered nurses who are currently working are asked to stay into another shift and those who are not on the schedule are called to come in.

*Staff who call off are given progressive discipline so they understand the importance of calling off for their scheduled shifts.

*Staffing ratios will be reviewed at Quality Assurance Process Improvement meetings

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