Pennsylvania Department of Health
HIGHLANDS REHABILITATION AND HEALTHCARE
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 46 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.


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

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on February 10, 2026, at Highlands Rehabilitation and Healthcare, 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 - Component: 01 - Tag: 0000

Facility ID #127402
Component 01
Main Building 01

Based on a Medicare/Medicaid Recertification Survey completed on February 10, 2026, it was determined that Highlands Healthcare and Rehabilitation Center was not in compliance with the following requirements of the Life Safety Code for an existing 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, fully sprinklered building, with a basement.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

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.

Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in multiple locations, affecting four of four floors.

Findings include:

1. Observation on February 10, 2026, at 11:00 a.m., revealed the facility exceeded the maximum allowable story height by one story.

Exit interview, on February 10, 2026, between 11:45 a.m., and 12:00 p.m., with the Facility Administrator and the Facilities Manager, confirmed the building construction deficiency.

Plan of Correction - To be completed: 03/18/2026

FSES was completed on 8/26/2024

Facility will maintain an up to date FSES.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

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.

Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain exit stair tower enclosures, in two locations, affecting one of four floors.

Findings include:

1. Observation on February 10, 2026, between 10:40 a.m., and 10:46 a.m., revealed the following:

a. 10:40 a.m., bar joist penetrations of the third floor portion of the west stair tower enclosure.
b. 10:46 a.m., bar joist penetrations of the center stair tower enclosure.

Exit interview, on February 10, 2026, between 11:45 a.m., and 12:00 p.m., with the Facility Administrator and the Facilities Manager, confirmed the stair tower enclosure deficiencies.

Plan of Correction - To be completed: 03/18/2026

Bar joists were sealed by the west stairs on third floor and center stairs on third floor.

Maintenance conducted an audit of bar joists by stairs and sealed as needed.

Maintenance will be reeducated on maintaining sealed bar joists by stairwells.

Maintenance/ Designee will audit stairs for bar joist penetrations weekly x4 and monthly x3 and report findings to monthly QAPI committee.

NFPA 101 STANDARD Exit Signage:

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: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based on observation and interview, it was determined the facility failed to install and maintain exit signage in one location, affecting one of four floors.

Findings include:

1. Observation on February 10, 2026, at 10:50 a.m., revealed the exit access corridor system lacked exit signage at the elevator lobby entrance.

Exit interview, on February 10, 2026, between 11:45 a.m., and 12:00 p.m., with the Facility Administrator and the Facilities Manager, confirmed the exit signage deficiency.

Plan of Correction - To be completed: 03/18/2026

Exit sign was added to the elevator lobby entrance.

Maintenance conducted an audit of exits to ensure signage is in place.

Maintenance will be reeducated on maintaining exit signage throughout the building.

Maintenance/ Designee will audit exits to ensure signage is in place weekly x4 and monthly x3 and report findings to monthly QAPI committee.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

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: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of four floors.

Findings include:

1. Observation on February 10, 2026, at 10:33 a.m., revealed the first floor, Activities Storage Room door was held open by unapproved means.

Exit interview, on February 10, 2026, between 11:45 a.m., and 12:00 p.m., with the Facility Administrator and the Facilities Manager, confirmed the hazardous area enclosure deficiency.

Plan of Correction - To be completed: 03/18/2026

Door to the activity storage room was closed immediately.

Maintenance conducted an audit of storage doors to ensure they were not propped open.

Maintenance will be reeducated on keeping the storage room door closed.

Maintenance/Designee will conduct audits of storage doors to ensure they are not propped open weekly x4 and monthly x3 and report findings to monthly QAPI committee.

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers in one location, affecting one of four floors.

Findings include:

1. Observation on February 10, 2026, at 11:22 a.m., revealed a portable fire extinguisher bulb, located within the first floor, DPW Suite, was not illuminated,

Exit interview, on February 10, 2026, between 11:45 a.m., and 12:00 p.m., with the Facility Administrator and the Facilities Manager, confirmed the fire extinguisher deficiency.

Plan of Correction - To be completed: 03/18/2026

DPW fire extinguisher bulb was replaced.

Maintenance conducted an audit of fire extinguisher bulbs and replaced as needed.

Maintenance will be reeducated on maintaining illuminated fire extinguishers.

Maintenance/Designee will conduct audits of fire extinguishers bulbs to ensure they are working properly weekly x4 and monthly x3 and report findings to monthly QAPI committee.

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor openings in four locations, affecting three of four floors.

Findings include:

1. Observation on February 10, 2026, between 10:32 a.m., and 11:35 a.m., revealed the following:

a. 10:32 a.m., the first floor, Break Room door was held open by unapproved means.
b. 10:40 a.m., the third floor, Resident Room 301 door required adjustment to fully latch.
c. 11:02 a.m., the distance between the second floor, Dining Room doors exceeded one-eighth inch.
d. 11:35 a.m., the first floor, Dietary doors required a coordination adjustment to fully close, and latch one to another.

Exit interview, on February 10, 2026, between 11:45 a.m., and 12:00 p.m., with the Facility Administrator and the Facilities Manager, confirmed the corridor opening deficiencies.

Plan of Correction - To be completed: 03/18/2026

The first floor break room door was closed immediately. The third floor door was tested by maintenance and fully latched. A strip was added to the second floor dining room door. A new door closure was added to the dietary doors.

Maintenance conducted an audit of break room doors to ensure they were not propped open, resident room doors to ensure proper latching, dining room doors to ensure proper distance, and dietary doors to ensure coordination is working properly.

Maintenance will be reeducated on maintaining corridor openings.

Maintenance/Designee will conduct random door audits weekly x4 and monthly x3 and report findings to monthly QAPI committee.

NFPA 101 STANDARD HVAC:

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: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on observation, interview, and documentation review, it was determined the facility failed to maintain heating, ventilation, and air conditioning in two instances, affecting four of four floors.

Findings include:

1. Observation on February 10, 2026, between 11:12 a.m., and 11:34 a.m., revealed the following:

11:12 a.m., the portable air conditioning unit, located at the second floor Nurse's Station, vented into interstitial spaces.
b. 11:34 a.m., the facility lacked documentation to support required four-year, fire damper preventative maintenance.

Exit interview, on February 10, 2026, between 11:45 a.m., and 12:00 p.m., with the Facility Administrator and the Facilities Manager, confirmed the HVAC deficiencies.

Plan of Correction - To be completed: 03/18/2026

The portable AC unit was removed from the second floor nurses station. Facility has four- year fire damper preventative maintenance documentation.

Maintenance conducted an audit of portable AC units and removed as necessary.

Maintenance will be reeducated on maintaining proper HVAC systems.

Maintenance/Designee will conduct audits of portable AC units to ensure proper ventilation and will maintain fire damper preventative maintenance weekly x4 and monthly x3 and report findings to monthly QAPI committee.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright � 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement