Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in
charge on each shift.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a
review of nursing staffing hours and ratios, observations and resident, family and staff interviews it was
determined that the facility failed to provide sufficient nursing staff to consistently provide timely quality of
care, services, and supervision necessary to maintain the physical and mental well-being of the residents in
the facility including Residents 1, 2, and 3.
Findings include:
Observations on November 14, 2023, at 11:45 AM on the A nursing unit revealed one nurse manager
working the desk at the nurse's station, two nurses working the medication carts and 3 nurse aides on duty.
Observations on the B nursing unit on November 14, 2023, revealed one nurse manager working the desk
at the nurse's station, two nurses working the medication carts, and 4 nurse aides on duty.
Observations of the A nursing unit on November 14, 2023, at 11:50 AM revealed Resident 1's call bell was
ringing in resident room [ROOM NUMBER]. Resident 2's call bell was also ringing in resident room [ROOM
NUMBER]. Resident 3 call bell was observed ringing in resident room [ROOM NUMBER].
An interview with Resident 2 on November 14, 2023, at 11:52 AM revealed she had been ringing her call
bell for at least 15 minutes and with no nursing staff responding. The resident stated at that time she was
ringing to be changed because her incontinence brief was soiled, and it was burning her skin and she was
uncomfortable.
Observations on the A nursing unit on November 14, 2023, at 12:00 PM revealed Employee 1, Nurse
Manager, was seated at the nursing desk working on the computer as the three residents' call bells
continued to sound. Employee 2, RN, arrived on the unit and was also observed at the nursing station.
Neither nurse answered the residents' call bells or checked on the residents to determine the assistance
required.
Employee 3, a nurse aide, was heard, yelling out from resident room [ROOM NUMBER] that she needed
help with a resident. Employee 2, RN, stated I can't help you because of my back and Employee 2, then
asked Employee 3 where the other nurse aides were. No nurse aides were available at that time as they
were assisting other residents. Employee 3 remained alone in resident room [ROOM NUMBER] awaiting
another assistance from another nurse aide as neither licensed nurse assisted with the resident's care.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 4
Event ID:
395566
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395566
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Highland Manor Rehabilitation and Nursing Center
750 Schooley Avenue
Exeter, PA 18643
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During this time the call bells in resident room [ROOM NUMBER], room [ROOM NUMBER], and room
[ROOM NUMBER] continued to sound and additional call bell began to sound, in resident rooms [ROOM
NUMBERS].
Observations on November 14, 2023, at 12:10 PM revealed Employee 2 was standing at a medication cart
next to resident room [ROOM NUMBER]. The call bells in resident rooms [ROOM NUMBERS] call bells
were still ringing. Employee 2, did not enter either resident room to assist Resident 1 or Resident 2 who
required assistance. Further observations revealed Resident 3 in room [ROOM NUMBER] call bell was still
ringing for assistance without response.
Observations on November 14, 2023, at 12:15 PM revealed Employee 3, nurse aide, was still in resident
room [ROOM NUMBER] assisting with a resident. The other nurse aides on the unit were in other resident
rooms assisting other residents on the unit. Rooms 127, 123, 114, 112, and 116 call bells were still
activated and ringing without response from licensed nursing staff present on the unit.
Employee 1 continued to work at the nurse's desk. Employee 2 was going between the medication and the
nursing station but did not respond to the residents' requests for assistance failing to answer the call bells.
Employee 4 RN was observed at a medication cart standing next to Resident 3's room. At the time of this
observation Resident 3's daughter came out and informed Employee 4 that her mother was soiled and
needed to be changed. Employee 4 did not go into the resident's room to assist the resident with
incontinence care, but instead stated we will find one of the aides.
Observations on November 14, 2023, at 12:20 PM revealed rooms 123, 114, 112, and 116 call bells were
still activated and ringing. Employee 3, nurse aide was still assisting the resident in room [ROOM
NUMBER]. Employees 2 and 4, licensed nurses, were standing at the medication carts. Resident 3's
daughter was still asking for help with her mother informing the licensed nurses that the resident was sitting
in a soiled brief that needed to be changed. Resident 2 was still sitting in her soiled brief and the licensed
nursing staff failed to assist the resident.
Observations on November 14, 2023, at 12:25 PM revealed rooms 123, 114, 112, and 116 call bells were
still activated and ringing.
An interview with Resident 3's daughter on November 14, 2023, at 12:25 PM revealed her mother had been
ringing the call bell for 30 minutes. The resident's daughter stated that her mother needs assistance of 3
people to care for her or she would have just changed her mother herself. Resident 3's daughter stated her
mother has been sitting in a wet brief and she is uncomfortable. At the time of the interview Employee 3,
nurse aide, approached the resident's room [ROOM NUMBER] to provide assistance to the resident.
An interview with Resident 2 on November 14, 2023, at 12:27 PM revealed the resident was [NAME]
ringing her call bell for assistance. The resident stated she was still sitting in a soiled brief and her bottom
was burning and really needed assistance. At this time the resident had been ringing her call bell for over
35 minutes since the first observation was conducted.
Employee 2, RN, on November 14, 2023, at approximately 12:30 PM asked the surveyor if the resident
needed assistance. At that time the surveyor relayed that the resident had been ringing her call bell for over
35 minutes and was soiled and needed assistance.
Observations at 12:30 PM on November 14, 2023, revealed Resident 2 was still waiting to be assisted
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395566
If continuation sheet
Page 2 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395566
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Highland Manor Rehabilitation and Nursing Center
750 Schooley Avenue
Exeter, PA 18643
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0725
Level of Harm - Minimal harm
or potential for actual harm
and changed as Employee 2 did not provide the incontinence care needed. The residents in rooms [ROOM
NUMBERS] were still ringing their call bells for assistance.
The facility failed to provide sufficient nursing staff to provide the necessary services to meet the clinical,
safety and care needs of the residents residing in the facility.
Residents Affected - Some
Observations revealed that the facility's licensed nursing staff failed to provide assistance to residents when
requested and failed to perform general direct nursing care to the residents when needed.
A review of the facility's weekly staffing records revealed that on the following dates the facility failed to
provide minimum nurse aide staff of 1:12 on the day and evening shift and 1:20 on the night shift based on
the facility's census.
November 2, 2023 - 4 nurse aides on the night shift, versus the required 6 for a census of 113.
November 3, 2023 - 5 nurse aides on the night shift, versus the required 6 for a census of 115.
November 4, 2023 - 9 nurse aides on the day shift, versus the required 10 for a census of 115.
November 4, 2023 - 9 nurse aides on the evening shift, versus the required 10 for a census of 115.
November 4, 2023 - 4 nurse aides on the night shift, versus the required 6 for a census of 115.
November 5, 2023 - 7 nurse aides on the evening shift, versus the required 10 for a census of 115.
November 5, 2023 - 3 nurse aides on the night shift, versus the required 6 for a census of 115.
November 6, 2023 - 5 nurse aides on the night shift, versus the required 6 for a census of 114.
November 7, 2023 - 4 nurse aides on the night shift, versus the required 6 for a census of 111.
November 8, 2023 - 5 nurse aides on the night shift, versus the required 6 for a census of 111.
November 9, 2023 - 8 nurse aides on the evening shift, versus the required 10 for a census of 111.
November 9, 2023 - 5 nurse aides on the night shift, versus the required 6 for a census of 111.
November 10, 2023 - 7 nurse aides on the evening shift, versus the required 9 for a census of 107.
November 10, 2023 - 5 nurse aides on the night shift, versus the required 6 for a census of 107.
November 11, 2023 - 7 nurse aides on the evening shift, versus the required 9 for a census of 107.
November 11, 2023 - 4 nurse aides on the night shift, versus the required 6 for a census of 107.
November 12, 2023 - 8 nurse aides on the evening shift, versus the required 9 for a census of 106.
November 12, 2023 - 4 nurse aides on the evening shift, versus the required 6 for a census of 106.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395566
If continuation sheet
Page 3 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395566
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Highland Manor Rehabilitation and Nursing Center
750 Schooley Avenue
Exeter, PA 18643
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0725
November 13, 2023 - 7 nurse aides on the day shift, versus the required 9 for a census of 107.
Level of Harm - Minimal harm
or potential for actual harm
November 14, 2023 - 7 nurse aides on the day shift, versus the required 9 for a census of 107.
Residents Affected - Some
A review of the facility's weekly staffing records revealed that on the following dates the facility failed to
provide minimum licensed practical nurse (LPN) staff of 1:25 on the day shift and 1:40 on the night shift
based on the facility's census.
November 2, 2023 - 2 LPN on the night shift, versus the required 3 for a census of 113.
November 3, 2023 - 2 LPNs on the night shift, versus the required 3 for a census of 115.
November 4, 2023 - 4 LPN on the day shift, versus the required 5 for a census of 115.
November 4, 2023 - 2 LPNs on the night shift, versus the required 3 for a census of 115.
November 5, 2023 - 4 LPNs on the day shift, versus the required 5 for a census of 115.
November 11, 2023 - 4 LPNs on the day shift, versus the required 5 for a census of 107.
November 11, 2023 - 2 LPNs on the night shift, versus the required 3 for a census of 107.
November 12, 2023 - 4 LPNs on the day shift, versus the required 5 for a census of 107.
November 5, 2023 - 2 LPNs on the night shift, versus the required 3 for a census of 107.
A review of the facility's weekly staffing levels revealed that on the following dates the facility failed to
provide minimum nurse staffing of 2.87 hours of general nursing care to each resident:
November 4, 2023 -2.50 direct care nursing hours per resident
November 5, 2023 -2.46 direct care nursing hours per resident
November 10, 2023 -2.76 direct care nursing hours per resident
November 11, 2023 -2.54 direct care nursing hours per resident
November 12, 2023 - 2.52 direct care nursing hours per resident
During the time period of November 2, 2023, through November 13, 2023, the facility provided an average
of 2.84 hours of general nursing care per resident failing to meet the minimum state regulatory requirement
for nursing time on these days.
28 Pa. Code 211.12 (c)(d)(1)(4)(5)(g)(i) Nursing services
28 Pa. Code 201.18 (e)(1)(2)(3)(6) Management
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395566
If continuation sheet
Page 4 of 4
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
FAQ · About this visit
Common questions about this visit
What happened during the November 14, 2023 survey of HIGHLAND MANOR REHABILITATION AND NURSING CENTER?
This was a inspection survey of HIGHLAND MANOR REHABILITATION AND NURSING CENTER on November 14, 2023. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at HIGHLAND MANOR REHABILITATION AND NURSING CENTER on November 14, 2023?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.