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

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

HIGHLAND MANOR REHABILITATION AND NURSING CENTER
Inspection Results For:

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HIGHLAND MANOR REHABILITATION AND NURSING CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on August 21, 2026, 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(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.

§483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

§483.10(f)(6) The resident has a right to participate in family groups.

§483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.

Observations:

Based on a review of facility policy, resident council meeting minutes, grievance documentation, and resident and staff interviews, it was determined the facility failed to make reasonable efforts to address concerns raised by the resident council and failed to keep residents informed regarding the status and outcome of identified concerns. The facility failed to ensure ongoing communication and timely follow-up regarding issues presented by four of four residents attending a resident council group meeting (Residents 112, 35, 26, and 58).

Findings include:

A review of the facility's "Grievance Policy" last reviewed on February 19, 2026, indicated all concerns and questions may be presented to the facility orally or in writing. the policy stated the administrator will follow up on all concerns and grievances registered by any resident or resident representative.

A review of the Minutes from a Resident Council meeting dated June 8, 2026, revealed concerns from residents that personal laundry was not being picked up and returned timely and a grievance was filed on June 8, 2026, regarding this concern.

A Review of the grievance filed June 8, 2026, revealed concerns with the laundry would be followed up on to ensure resolution. The grievance was signed as resolved as of June 9, 2026.

A group meeting conducted on August 18, 2026, at 10:00 AM with four residents (Residents 112, 35, 26, and 58) revealed unanimous reports that the facility failed to address their complaints regarding the timeliness of laundry service in the facility. All residents in attendance stated they felt the timeliness especially of the return of personal laundry is still on ongoing, unresolved concern.

The facility was unable to provide documented evidence that residents were satisfied with the outcome of the grievance regarding personal laundry service despite indicating the grievance was resolved on June 9, 2026.

During an interview on August 19, 2026, at 10:10 AM, the Nursing Home Administrator (NHA) could not provide documented evidence of resident satisfaction in addressing grievances raised during Resident Council meetings and written grievances.

28 Pa. Code 201.18 (e)(1)(4) Management.
28 Pa. Code 201.29(a) Resident Rights.
28 Pa. Code 211.10 (d) Resident care policies.

Plan of Correction - To be completed: 09/29/2026

- Social Service Director/Designee will meet with R112, R35, R26, and R58 to discuss concern with personal laundry and resolution to same and documented on a concern form for each.
- Residents/families that have concerns with personal laundry will be reviewed in the past 30 days to ensure concerns were resolved timely and documented on concern form. Personal laundry process will be reviewed and revised.
- Staff will be educated on grievance policy. Laundry staff will be educated on the revised laundry process to ensure timely and accuracy of the personal laundry process.
- Audit of the concerns forms will be completed weekly x4, then monthly x2 by SSD/designee to ensure thorough and timely resolution. Random audit of personal laundry will be completed weekly x4, then monthly x2 by Environmental Director/designee to ensure laundry is picked up, processed, and returned timely.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Observations:

Based on select facility policy, observations, clinical record review, and staff interview, it was determined the facility failed to maintain oxygen equipment in a functional and sanitary manner for one resident out of 24 residents reviewed (Resident 65).

Findings include:

Review of the facility policy "Care of Oxygen Supplies" last reviewed August 2026, indicated when a resident is not using tubing/set up (nasal cannula, flexible plastic tubing with small prongs inserted into the nostrils to deliver supplemental oxygen) it should be carefully removed and placed in the bag supplied with set up. If not properly stored in bag the tubing should be replaced, assure it is dated for date it was changed.

Review of Resident 65's clinical record revealed the resident was admitted to the facility on July 27, 2020, with diagnoses to include acute and chronic respiratory failure (condition when the lungs cannot get enough oxygen into your blood or remove enough carbon dioxide from the body).

A physician order initially dated August 11, 2026, noted an order for oxygen 2 liters/minute via nasal cannula as needed for shortness of breath.

An observation on August 20, 2026, at 11:35 AM revealed Resident 65's oxygen tubing with nasal cannula was placed directly on the mattress.

Observation on August 20, 2026, at 12:10 PM revealed Resident 65's oxygen tubing with nasal cannula was rolled up and placed on top of the oxygen concentrator and not in a plastic bag as per facility policy.

Interview with Employee 2 NA (nurse aide) on August 20, 2026, at 12:15 PM noted that the resident's oxygen tubing and cannula was removed prior to the resident's shower, placed on the mattress, and then placed on top of the oxygen concentrator so that the bed could be made.

Interview with the Director of Nursing on August 21, 2026, at approximately 10:20 AM confirmed that Resident 65's respiratory equipment was to be maintained in a sanitary manner and bagged when not in use.

28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.
28 Pa. Code 211.10 (a)(c)(d) Resident Care Policies.

Plan of Correction - To be completed: 09/29/2026

- Resident 65 oxygen was noted as not needed this day and prn ordered oxygen was discontinued and concentrator and oxygen tubing removed from room.
- Residents currently receiving oxygen therapy will be audited to assure bag with name is on concentrator for proper storage, when not in use. DON or designee
- Education to hands on staff to be completed to ensure they are aware of process and how to store cannula when not in use. Staff Educator or Designee
- Random audits to be completed to ensure bags in place for storage and is being utilized Weekly times 4 and monthly times 2. DON or designee. Trends will be reviewed at QAPI Meeting monthly.

483.40 REQUIREMENT Behavioral Health Services:

§483.40 Behavioral health services.
Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.

Observations:

Based on clinical record review and staff interviews, it was determined the facility failed to ensure that necessary behavioral health care and services were provided to attain or maintain the highest practicable mental and psychosocial well-being for one of 24 residents reviewed. (Resident 2).

Findings include:

A review of Resident 2's clinical record revealed the resident was admitted to the facility on April 4, 2025, with diagnoses which included PTSD (Post Tramautic Stress Disorder a serious mental health condition that can develop after an individual experiences or witnesses a traumatic event), and Bipolar Disorder (a mental disorder characterized by periods of depression and abnormally elevated mood, lasting days to weeks, and in some cases months).

A quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated June 12, 2026, indicated that Resident 2 had a BIMS (brief screener that aids in detecting cognitive impairment) score of 8 indicating moderate cognitive impairment.

Review of Resident 2's care plan revealed a focus area regarding her mental health diagnoses, including bipolar disorder, initiated by the facility on November 12, 2025. This care plan included consulting with psychiatric services as needed.

A review of the resident's physician's orders revealed an order dating from admission on April 4, 2025, for psych services with an outside psychiatric provider.

A review of Resident 2's clinical record from April 4, 2025, through end of survey August 24, 2026, revealed the resident was never seen by the facility's contracted psychiatric provider.

A review of the clinical record revealed the resident had intermittent behaviors including refusal of care and being physically abusive with staff.

A review of a progress note dated July 26, 2026, indicated the resident had punched a staff member in the face. The resident stated at that time I don't care, I don't like her.

There was no evidence that the facility developed or implemented additional services to address the resident's ongoing behavioral health needs, and psychosocial stressors.

During an interview with the Nursing Home Administrator (NHA) on August 20, 2025, at 10:00 AM, the NHA was unable to provide evidence that the resident had been seen by psychiatric services to address the need for behavioral health interventions to maintain the resident's highest practicable level of mental and psychosocial well-being.

28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 09/29/2026

- Resident 2 was seen by Psych CRNP on 8/21/26 with recommendations and same were followed.
- Audit for all residents with psychiatric diagnosis of PTSD or bipolar disorder to assure they have been seen by supportive services. SS or designee
- Education to Social Service to assure anyone admitted with psychiatric diagnosis PTSD or bipolar are referred to Supportive Services for follow-up. Staff Educator
- Random audits of admissions to assure Supportive Services notified of need for services. Weekly times 4 and monthly times 2 SS or Designee. Trends will be reviewed at QAPI meeting monthly.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(f). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Observations:

Based on select facility policy, a review of clinical records, and staff interview, it was determined that the facility failed to implement procedures to maintain records of controlled drugs and ensure accurate drug administration for 1 out of the 24 residents sampled (Resident 9).

Findings include:

A review of facility policy entitled "Controlled Substances" last reviewed by the facility on February 19, 2026, revealed that the facility will comply with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of controlled medications.

A review of clinical records revealed the facility utilizes an Individual Patient Controlled Substance Record to track, monitor, and reconcile each controlled medication (a drug that the government tightly regulates because it carries a risk of abuse, misuse, physical dependence, or addiction). Additionally the facility tracks medication administration for each resident by way of the Medication Administration Record (MAR). The MAR indicates the medication administered, time and date of administration, staff administering the medication, pain prior to the administration of medication, and clinical rationale for the administration of medication.

A clinical record review revealed Resident 9 was admitted to the facility on November 7, 2021, with diagnoses which included Parkinson's Disease (a long-term brain disorder that causes problems with movement, balance, and coordination) and Rheumatoid Arthritis (a long term disease where the body fights its own joints causing pain, swelling and warmth).

A review of physician orders revealed Resident 9 was admitted to hospice services on February 16, 2026. An order dated March 4, 2026, indicated the resident was to receive Morphine Sulfate Oral Solution (narcotic medication) 20 mg (milligram)/ml (milliliter) administer 0.25 ml. every three hours as needed for pain

A comparison of Resident 9's Individual Patient Controlled Substance Record with the MAR from February 21, 2026, through August 21, 2026, revealed an entry indicating Morphine Sulfate was utilized according to Resident 9's Individual Patient Controlled Substance Record. However, there was no documented evidence in Resident 9's MAR indicating the medication was administered on the following dates:
May 1, 2026, at 10:00 PM

A comparison of Resident 9's Individual Patient Controlled Substance Record with the MAR for February 21, 2026, through August 21, 2026, revealed four entries indicating Morphine Sulfate was documented as administered on the MAR. However, there was no corresponding documentation in the Individual Patient Controlled Substance Record indicating the medication was removed from inventory on the following dates:
July 14, 2026, at 12:34 AM
July 25, 2026, at 7:52 PM
July 28, 2026, at 4:40 PM
August 8, 2026, 9:17 PM

During an interview on August 21, 2026, at 10:15AM, the Director of Nursing (DON) acknowledged the above findings related to the facility's failure to implement effective procedures to reconcile Resident 9's-controlled substance medications.

28 Pa Code 211.5(f)(x) Medical records.
28 Pa Code 211.9(a)(1)(k) Pharmacy services.
28 Pa Code 211.12 (d)(1)(3)(5) Nursing services.
28 Pa Code 211.10 Resident care policies.

Plan of Correction - To be completed: 09/29/2026

- Unable to retroactively fix controlled substance documentation for Resident 9 – New bottle of medication ordered, and remaining medication of prior bottle noted to be leaking replaced. Education for both nurses involved was completed. DON or designee
- Audits of narcotic medications currently being used comparing sheet to MAR to assure documentation is present. DON or Designee
- Education to licensed staff to ensure they follow policy and procedures in documentation of narcotics. Staff Educator of Designee
- Random audits of narcotic documentation is being done properly weekly times 4 and monthly times 2 DON of Designee. Trends will be reviewed at QAPI meeting monthly.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based on select facility policy, observations, and staff interview, it was determined the facility failed to implement procedures to ensure acceptable storage for medications on one of two nursing units observed. (100-unit Medication Storage Room)

Findings include:

A review of facility policy entitled "Disposal of Medications and Medication Related Supplies", last reviewed on February 19, 2026, revealed medications will be disposed of in accordance with federal, state and local regulations governing management of non- hazardous pharmaceuticals, hazardous waste and controlled substances.

Observations of the 100 nursing unit medication storage room on August 18, 2026, at 10:15 AM revealed the following:
Two boxes of Heparin (a blood thinner used to prevent and treat blood clots)
Two single use vials of Iron sucrose(an injection form of iron replacement)
One single use vial of Cyanocobalamin( injectable form of Vitamin B12)
One single use vial of Meropenem (a broad spectrum antibiotic)
One vial of Cefepime (a broad spectrum antibiotic)
Twenty five vials of Piperacillin and Tazobactam (a combination of antibiotics used to treat a wide range of bacterial infections)

Interview with Employee 1, a licensed practical nurse (LPN), during the time of the observation, revealed the the medications belonged to residents who have been discharged from the facility and should have been destroyed.

Interview with the Director of Nursing and the Nursing Home Administrator on August 19, 2026 at 11:30 AM confirmed that the facility's expectation is for discontinued resident medications to be removed from the medication room by a licensed nurse and destroyed in accordance with facility policy.

28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services.
28 Pa. Code 211.12 (d)(3)(5) Nursing services.
28 Pa Code 211.10 Resident care policies.

Plan of Correction - To be completed: 09/29/2026

- Items found in medication room were destroyed as per facility policy the day were found in Medication Room.
- Audit of both med rooms completed to ensure there are no medications of residents who are no longer in building or no longer on medications. DON or Designee
- Education to licensed staff on proper procedure to destroy medications with use of drug buster. Educator or designee
- Random audits of medication rooms to ensure staff is destroying medications no longer needed. Weekly times 4 monthly times 2. DON or Designee. Trends will be reviewed at QAPI meeting monthly

§ 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.

Plan of Correction - To be completed: 09/29/2026

- Unable to correct the LPN staffing 4/4/26 day shift, 4/4/26 night shift, 4/5/26 night shift, 4/6/26 night shift, 4/7/26 night shift, 7/3/26 day shift, 7/3/26 evening shift, 7/3/26 night shift, 7/4/26 day shift, 7/4/26 night shift, 7/5/26 evening shift, 7/5/26 night shift, 7/6/26 night shift, 7/7/26 night shift, 7/8/26 night shift, 7/9/26 night shift, 8/14/26 night shift, 8/15/26 day shift, 8/15/26 night shift, 8/16/26 day shift, 8/16/26 night shift, 8/18/26 night shift, and 8/20/26 night shift.
- LPN staffing will be reviewed for the next 14 days to ensure LPN are staffed at state ratios.
- The NHA/designee will educate Nursing Admin, Staff Scheduler, and RN supervisors on staffing ratio requirements for LPNs and to notify DON/designee of call offs. 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. Use of higher-level staff may be used to assist in meeting updated staffing requirements. Additional agencies will be contracted to support the staffing needs of the facility.
- 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 x3.

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