Pennsylvania Department of Health
HIGHLANDS REHABILITATION AND HEALTHCARE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

HIGHLANDS REHABILITATION AND HEALTHCARE
Inspection Results For:

There are 126 surveys for this facility. Please select a date to view the survey results.

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HIGHLANDS REHABILITATION AND HEALTHCARE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Survey in response to a Complaint, completed on August 28, 2024, at Highlands Rehabilitation and Healthcare, it was determined that there were no federal deficiencies identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care; however, the facility was not in compliance with 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.

Plan of Correction - To be completed: 10/01/2024

1. Facility cannot retroactively correct nurse aide staffing ratio.

2. Director of Nursing/Designee will conduct an initial audit of the past two weeks' schedule to determine if nurse aide ratio is in compliance.

3. Director of Nursing or Designee will re-educate the scheduler on the proper nurse aide staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made.

4. Director of Nursing/Designee will conduct random audits of nurse aide staffing weekly for four weeks, then monthly for two months thereafter to verify proper nurse aide ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.

§ 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 a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 25 residents on the day shift for seven of 21 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed the following staff scheduled for the following resident census:

Day Shift (requires one LPN per 25 residents):

August 10, 2024, 4.00 LPNs for a census of 107; requires 4.28 LPNs
August 11, 2024, 3.88 LPNs for a census of 107; requires 4.28 LPNs
August 13, 2024, 4.06 LPNs for a census of 107; requires 4.28 LPNs
August 17, 2024, 4.03 LPNs for a census of 105; requires 4.20 LPNs
August 18, 2024, 3.91 LPNs for a census of 105; requires 4.20 LPNs
August 24, 2024, 3.97 LPNs for a census of 105; requires 4.20 LPNs
August 25, 2024, 2.91 LPNs for a census of 105; requires 4.20 LPNs

An interview with Employee 1, scheduler, on August 28, 2024, at 2:24 PM confirmed the facility did not meet the regulatory LPN-to-resident ratio as evidenced above.

The Nursing Home Administrator and Director of Nursing were informed of the above findings on August 28, 2024, at 2:45 PM.

Plan of Correction - To be completed: 10/01/2024

1. Facility cannot retroactively correct LPN staffing ratio.

2. Director of Nursing/Designee will conduct an initial audit of the past two weeks schedule to determine if LPN ratio is in compliance.

3. Director of Nursing/Designee will re-educate the scheduler on the proper LPN staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made.

4. Director of Nursing/Designee will conduct random audits of LPN staffing weekly for four weeks, then monthly for two months thereafter to verify proper LPN ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure the total of nursing care hours provided in each 24-hour period was a minimum of 3.2 hours per patient day (PPD), effective July 1, 2024, for five of 21 days reviewed.

Findings include:

Review of nursing staff care hours revealed that the facility failed to meet the minimum hours per patient day for the following days:

August 10, 2024, with 3.07 hours per resident per day.
August 11, 2024, with 2.88 hours per resident per day.
August 17, 2024, with 2.63 hours per resident per day.
August 18, 2024, with 2.85 hours per resident per day.
August 24, 2024, with 3.04 hours per resident per day.

An interview with Employee 1, scheduler, on August 28, 2024, at 2:24 PM confirmed the facility did not meet the regulatory minimum 3.2 hours per patient day as evidenced above.

The Nursing Home Administrator and Director of Nursing were informed of the above findings on August 28, 2024, at 2:45 PM.

Plan of Correction - To be completed: 10/01/2024

1. Facility cannot retroactively correct staffing PPD.

2. Director of Nursing/Designee will conduct an initial audit of the past two weeks' schedule to determine if PPD is in compliance.

3. Director of Nursing/Designee will re-educate the scheduler on the proper PPD. The facility will hold labor meetings Monday-Friday to verify PPD is made.

4. Director of Nursing/Designee will conduct random audits of facility PPD weekly for four weeks, then monthly for two months thereafter to verify proper PPD hours. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.

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