Pennsylvania Department of Health
HIGHLAND MANOR REHABILITATION AND NURSING CENTER
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 38 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:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID# 340902
Component 01
Main Building

Based on a Relicensure Survey completed on October 28, 2025, it was determined that Highland Manor Rehabilitation and Nursing 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 483.70(a).

This is a one story, Type III (200), unprotected, ordinary building, with a partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Doors with Self-Closing Devices:

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0223

Based on observation and interview, it was determined the facility failed to maintain two doors with self-closing devices, affecting two of two floors.

Findings include:

1. Observation on October 28, 2025, between 10:32 am, and 11:07 am, revealed the following:

a. At 10:32 am, Basement Level, Nurses Skills Lab door failed to positively latch into frame when tested.
b. At 11:07 am, Chapel door failed to positively latch into frame when tested.

Exit interview with the Facility Administrator and Facilities Manager on October 28, 2025, at 11:30 am, confirmed the self-closing doors failed to latch.

Plan of Correction - To be completed: 11/18/2025

- The doors to the nurse's skills lab and the door to the chapel were adjusted to positive latch into the frame.
- Doors with self-closures were checked to ensure positive latch into the frame.
- Maintenance staff will be educated to ensure doors with self-closures positive latch into the frame.
- Doors with self-closures will be audited monthly x3 by maintenance director/designee to ensure doors positive latch into the frame. Trends will be reviewed at QAPI monthly.

NFPA 101 STANDARD Emergency Lighting:

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on documentation review and interview, it was determined the facility failed to maintain emergency lighting, affecting one of two floors.

Findings include:

1. Review of documentation on October 28, 2025, between 9:30 am, and 10:15 am, revealed the facility lacked yearly, ninety-minute "bleed" or drain testing of the battery back-up emergency lighting.

Exit interview with the Facility Administrator and Facilities Manager on October 28, 2025, at 11:30 am, confirmed the emergency lighting deficiency.

Plan of Correction - To be completed: 11/18/2025

- A 90 minute "bleed" test was completed on the battery back-up emergency lighting and documented.
- A 90 minute "bleed" test will be completed annually.
- Maintenance staff will be educated to performing an annual 90 minute "bleed" test on battery back up lighting and document findings.
- 90 minute bleed testing will be audited annually to ensure bleed test was completed and documented. Findings will be reviewed at QAPI.

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 maintain exit signage in one location, affecting one of two floors.

Findings include:

1. Observation on October 28, 2025, at 10:46 am, Dietary, revealed exit sign was not illuminated, located above rear exit door.

Exit interview with the Facility Administrator and Facilities Manager on October 28, 2025, at 11:30 am, confirmed the exit sign was not illuminated.

Plan of Correction - To be completed: 11/18/2025

- The illuminated exit signage located in dietary was replaced.
- The exit signage throughout the facility was assessed to ensure exit signage is illuminated and visible.
- Maintenance staff will be educated by NHA/designee to ensure exit signages are visible and illuminated.
- Illuminated exit signage will be randomly audited monthly x3 by Maintenance Director/designee to ensure signage is illuminated and visible. Trends will be reviewed at QAPI monthly.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

Hazardous Areas - Enclosure
2012 EXISTING
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. 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

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 hazardous area enclosures in one location, affecting one of two floors.

Findings include:

1. Observation on October 28, 2025, at 10:55 am, A-Side, Soiled Utility room door failed to positively latch into frame when tested.

Exit interview with the Facility Administrator and Facilities Manager on October 28, 2025, at 11:30 am, confirmed the door failed to latch.

Plan of Correction - To be completed: 11/18/2025

- The door to A-side soiled utility room was adjusted to positive latch into the frame.
- The doors to hazardous area enclosures will be reviewed to ensure positive latch into the frame.
- Maintenance staff will be educated to ensure doors hazardous area enclosures positive latch into the frame.
- Doors to hazardous area enclosures will be audited monthly x3 by maintenance director/designee to ensure doors positive latch into the frame. Trends will be reviewed at QAPI monthly.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on documentation review and interview, it was determined the facility failed to maintain the fire alarm system in one instance, affecting the entire facility.

Findings include:

1. Review of documentation on October 28, 2025, between 9:30 am, and 10:15 am, revealed the facility lacked records to support the required bi-annual sensitivity test for the smoke detectors. (Lasted documented on 3/16/2023).

Exit interview with the Facility Administrator and Facilities Manager on October 28, 2025, at 11:30 am, confirmed the lack of documentation.

Plan of Correction - To be completed: 11/18/2025

- Sensitivity test for smoke detectors is scheduled for 12/ /25.
- Sensitivity testing for smoke detectors will be conducted every two years and documented.
- Maintenance staff will be educated to ensure sensitivity testing is conducted for smoke detectors at least every 2 years and documented.
- Fire alarm system will be audited to ensure sensitivity of smoke detectors are conducted at least every 2 years. Results will be reviewed at QAPI meeting.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of two floors.

Findings include:

1. Observation on October 28, 2025, at 10:46 am, Rear Hall, revealed an unsealed penetration of the sealed corridor ceiling, due to water damage.

Exit interview with the Facility Administrator and Facilities Manager on October 28, 2025, at 11:30 am, confirmed the unsealed penetration in the ceiling.

Plan of Correction - To be completed: 11/18/2025

- The penetration in ceiling of Rear Hall was sealed.
- The facility will be assessed to ensure no penetrations through smoke barriers.
- Maintenance Director will be educated by NHA to ensure the facility is free of penetrations through smoke barriers.
- The facility will be randomly audited by the maintenance director to ensure free of penetrations through smoke barriers. Trends will be reviewed at QAPI meeting monthly.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, the facility failed to maintain electrical wiring and the proper use of electrical equipment in one of seven smoke compartments.

Findings include:

1. Observation on October 28, 2025, at 10:57 am, revealed the use of a surge suppressor to power a microwave inside the employee break room.

Exit interview with the Facility Administrator and Facilities Manager on October 28, 2025, at 11:30 am, confirmed the use of surge suppressor.

Plan of Correction - To be completed: 11/18/2025

- The surge suppressor was immediately removed from the employee breakroom.
- The facility was assessed to ensure no surge suppressor are utilized for non-PCREE.
- NHA will educate Maintenance Director/designee to ensure surge suppressors are not utilized for non-PCREE.
- Facility will be audited monthly x3 by Maintenance Director/designee to ensure surge suppressors are not used for non-PCREE. Trends will be reviewed at QAPI meeting monthly.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, the facility failed to properly secure oxygen cylinders, on one of two floors.

Findings include:

1. Observation on October 28, 2025, at 10:59 am, revealed an unsecured oxygen "D" cylinder, being stored horizontally on top of other cylinders, in the oxygen storage room.

Exit interview with the Facility Administrator and Facilities Manager on October 28, 2025, at 11:30 am, confirmed the unsecured oxygen cylinder.

Plan of Correction - To be completed: 11/18/2025

- The unsecured oxygen "D" cylinder was immediately removed for the top of other cylinders and stored properly
- The facility will be assessed to ensure oxygen "D" cylinders are stored properly.
- Maintenance staff will be educated to ensure oxygen "D" cylinders are stored properly.
- Oxygen "D" cylinders will be audited monthly x3 by maintenance director/designee to ensure proper storage of cylinders. Trends will be reviewed at QAPI meeting monthly.

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