Pennsylvania Department of Health
HIGHLAND MANOR REHABILITATION AND NURSING CENTER
Patient Care 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

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
HIGHLAND MANOR REHABILITATION AND NURSING CENTER
Inspection Results For:

There are  100 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.
HIGHLAND MANOR REHABILITATION AND NURSING CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Complaint Survey completed on March 6, 2024, it was determined that the Highland Manor Rehabilitation and Nursing Center was in not compliance with the following 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.



 Plan of Correction:


483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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.
483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:

Based on review of minutes from the Residents' Council meeting and resident and staff interviews it was determined that the facility failed to provide care in a manner and environment, which promotes each resident's quality of life, by failing to respond timely to residents' request for assistance as evidenced by experiences reported by five residents out of five sampled (Residents 14, 11, 9, 13 and 10 ).

Findings include:

During interviews conducted throughout the day tour of duty on March 6, 2024, the residents stated that they feel the facility is not adequately staffed because they wait extended periods of time for staff to respond to their requests for assistance, including untimely responses to their requests via the nurse call bell system.

A review of minutes from the Residents' Council meeting on February 1, 2024, revealed that Resident 14 was requesting staff assignments be reassessed as he has been left in the bathroom for long periods of time when his assigned aide is off the floor. He reported that staff tell him they do not have him on their assignment and do not provide the necessary assistance, which has caused him to wait extended periods of time in the bathroom.

Interview with Resident 11 on March 6, 2024, at 10:43 AM revealed that she feels that short staffing and agency nursing staff are a problem in the facility. She stated that over that last couple of days "I would ring the bell to use the bathroom because I can't do it myself. I had to wait over an hour. I couldn't hold it and, unfortunately, I soiled myself."

Interview with Resident 9 on March 6, 2024, at 11:15 AM, revealed that she has waited over 2 hours for staff to answer her call bell. The resident stated that these long waits often occur an hour or so around shift changes. Resident 9 reported that on March 4, 2024, she was put in bed at 7:30 PM. At 1:00 AM an aide came in to check if the resident needed to be changed, and the resident replied that she did not at that time. Resident 9 stated she woke at 5:00 AM and activated the call bell as she needed to use the bathroom at that time. No one answered her call bell until 6:20 AM, when an aide "peeked in" the resident's room and said she would tell the other girls that she needed to be changed. Resident 9 stated that she soiled herself waiting for staff assistance. It was not until 7:30 AM, 2.5 hours after Resident 9 activated her call bell for assistance, that a nurse aide came in the resident's room to provide assistance. Resident 9 stated that she was so saturated with urine by that time that they had to change all the bed linens. She stated, "I was so embarrassed, but I couldn't help it, I had to go."

Interview with Resident 13 on March 6, 2024, at 11:30, revealed that the resident stated he has learned to do everything for himself because staff "take forever to answer the call bell" and provide assistance when needed.

Interview with Resident 10 on March 6, 2024, at 12:00 PM, revealed that he has waited over an hour for staff to answer his call bell. The resident stated that these waits occur mostly on 2nd shift (evening shift). He further stated he feels that short staffing is a problem in the facility that creates these long waits for residents to receive personal care and assistance when requested from nursing staff.

Interview on March 6, 2024, at approximately 2:15 PM with the Director of Nursing (DON) verified that it is her expectation that all residents be treated with dignity and respect. The DON was unable to explain why multiple residents are reporting untimely staff response times to their call bells and requests for assistance, resulting in the residents' feelings that the facility is not adequately staffed, which was negatively affecting the residents' quality of life in the facility.


28 Pa. Code 201.18 (e)(1) Management

28 Pa. Code 201.29 (a) Resident Rights

28 Pa. Code 211.12 (c)(d)(4)(5) Nursing Services







 Plan of Correction - To be completed: 04/02/2024

Step 1: Unable to retroactively address for residents 14, 9,11, and 10.
Residents 13 is Independent for all ADL's.
Step 2: Interview will be completed with residents with BIMS greater than 12 concerning call light wait times. (Social Service of designee)
Step 3: Education to staff in each department on responding to call lights promptly and meeting needs of resident or getting someone who can address resident's needs. Licensed nurse to check random call lights to assure resident needs met timely. (Clinical Educator or designee)
Step 4: Random interviews of resident with BIMS greater than 12 and call bell response audits randomly throughout the day weekly X4 Monthly X2 with results to QAPI monthly for three months.

483.60(d)(6) REQUIREMENT Drinks Avail to Meet Needs/Prefs/Hydration: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.
483.60(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(6) Drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration.
Observations:

Based on observation, review of clinical records and select facility policy, and resident and staff interviews, it was determined that the facility failed to ensure fresh water was consistently readily accessible to residents to promote adequate hydration, resident preference and comfort for five out of 14 residents reviewed (Residents 11, 9, 12, 13, and 2).

Findings include:

A review of the facility policy titled "Water Pass" provided by the facility on March 6, 2024, indicated that the facility will provide the residents with fresh water every shift and that straws, cups, and lids are changed at a minimum of every three days.

During an interview with Resident 11 on March 6, 2024, at 10:43 AM, the resident expressed frustration that she has to consistently ask staff to provide fresh drinking water, and staff do not routinely provide fresh drinking water daily. She stated "you have to ask for it, and even then, they're so busy, they forget. My son got me a cup yesterday, but no staff member has been in to give me any (fresh water) since then."

During an interview with Resident 9 on March 6, 2024, at 11:15 AM, she reported that staff do not provide fresh drinking water every shift and that the only drinking water she receives is the one she gets on her breakfast tray. She stated, "I have to ask them every day for cup of ice." Observation at the time of the interview revealed a Styrofoam cup with lid and straw in it on which on the side of the cup was written the resident's room number and bed location (A or B) dated February 29, 2024.

During an observation in Resident 12's room on March 6, 2024, at 11:25 AM, revealed a Styrofoam cup with lid and straw in it on the nightstand, out of reach of the resident on which was written, on the side of the cup, the resident's room number, bed location, and the date of February 29, 2024.

During an interview with Resident 13 on March 6, 2024, at 11:30 AM, he reported that "I get it (fresh water) myself. No one comes in to give me fresh water, so I go across the hall and get it myself." Observation at the time of the interview revealed a Styrofoam cup wit a lid and straw in it, on which was written, on the side of the cup, the resident's room number, bed location, and date of February 29, 2024.

During an interview with Employee 1 (nurse aide) on March 6, 2024, at 11:35, she confirmed that the Styrofoam cups for drinking water, observed in the rooms of Residents 11, 12, and 13 were dated six days ago, February 29, 2024, and that Resident 12's cup was also out of the resident's reach.

Observation in Resident 2's room on March 6, 2024, at 11:45 AM, revealed no water cup or other beverage available to the resident. Review of Resident 2's care plan revealed that the resident was on a regular diet with thin liquids and was independent with self-feeding.

Interview with Employee 2 (licensed practical nurse) on March 6, 2024, at 11:48 AM, confirmed that Resident 2 was independent with drinking thin liquids and able to manipulate the water cup independently. She also confirmed the absence of fresh water or another beverage available to Resident 2.

During an interview on March 6, 2024, at approximately 12:40 PM, the Director of Nursing (DON) stated that it is facility policy that the water pass is to be conducted once per shift and as needed. The DON stated it is facility policy to change straws, cups and lids every three days and as needed. The NHA confirmed that the facility failed to provide clean water drinking cups every three days and failed to demonstrate that fresh ice water was readily accessible as preferred by residents to promote adequate and hydration and comfort for residents.


28 Pa. Code 211.12 (d)(3)(5) Nursing services.


















 Plan of Correction - To be completed: 04/02/2024

Step 1: Unable to retroactively address for residents 11,9,12,13 and 2.

Step 2: Cups, straws and lids will be supplied by 11-7 shift with resident room number and dated at least every three days. Specific CNA staff assignments will be done to assure fresh water is provided on each shift for each resident that is allowed water at the bedside. Charge nurse will assure ice water is passed by assigned CNA.

Step 3: Education to hands on staff including nurses on importance of water distribution on each shift by assigned CNA and assurance that cups are within reach of residents. Charge nurse to assure pass occurs. Night shift to assure cups are changed at least every three days and confirmed by charge nurse or nursing supervisor. (clinical educator or designee)

Step 4: Audits will be completed to assure cups are dated correctly, and fresh water passed on each shift weekly times 4 and monthly x 2 with results to QAPI monthly for a period of three months.
211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on review of nursing time schedules and staff interviews, it was determined that the facility administrative staff failed to provide a minimum of one nurse aide per 12 residents during the day and evening shifts, and one nurse aide per 20 residents during the night shift on one of seven days reviewed. (2/18/24)

Findings include:

Review of facility census data indicated that on 2/18/24, the facility census was 101, which required 8.5 nurse aides during the evening shift.

Review of the nursing time schedules revealed that only 8 nurse aides provided care on the evening shift on 2/18/24. No additional excess higher-level staff were available to compensate this deficiency.



 Plan of Correction - To be completed: 04/02/2024

- Unable to correct the CNA staffing 2/18/2024.
- CNA staffing will be reviewed for the past 14 days to ensure CNA are staff to state ratios. CNA hourly rates were increased on 3/3/2024 to hire additional staff.
- The NHA/designee will educate Nursing Admin, Staff Scheduler, and RN supervisors on staffing ratio requirements. Phone lists for staff and agencies are provided to Nursing Admin, Staff Scheduler, and RN supervisors to assist in filling shift due to call-offs.
- NHA/designee will randomly audit staffing levels weekly x4 then monthly x2 to ensure staffing levels are meeting state requirements. Trends will be reviewed at QAPI meeting monthly for a period of three months.


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

Visit the PA Power Port