Highland Manor Rehab: Catheter Training Failures - PA
The resident at Highland Manor Rehabilitation and Nursing Center had been admitted with urinary retention and an enlarged prostate, conditions that made a specialized catheter called a coude not optional but necessary. The curved-tip device was listed on his care plan. What wasn't listed anywhere, inspectors found, was evidence that a single nurse at the facility had ever been formally trained to manage it.
The night shift Licensed Practical Nurse, identified in inspection records only as Employee 2, told the resident his obstructed catheter would have to stay that way until day shift arrived. She later told the Director of Nursing she wasn't comfortable changing a coude catheter because of her lack of familiarity with it. She did not call a supervising RN. She did not seek assistance from anyone. She waited.
The inspection, completed May 27, 2026, stemmed from a complaint. What investigators found when they looked into it went well beyond one nurse on one night shift.
Four other licensed nurses at the facility, Employees 1, 3, 4, and 5, were interviewed between 2:10 and 2:30 that afternoon. All four said the same thing: they had learned about catheters in nursing school, and some had used coude catheters at previous jobs, but Highland Manor had never provided facility-specific education, training, competency evaluation, or skills validation for coude catheter care. Not for insertion. Not for replacement. Not for routine management.
That was five nurses asked. Five nurses said the same thing.
The facility's own competency training documentation made the gap concrete. The skilled nursing competency list included nephrostomy tubes, which drain urine directly from the kidney through the skin of the lower back, and suprapubic catheters, which are surgically inserted through the abdomen. Neither of those is a routine procedure. But the list did not include standard Foley catheter insertion, Foley catheter management, or coude catheter care of any kind.
The Director of Nursing, interviewed at 2:45 PM on the day of the inspection, could not produce documentation showing that licensed staff had completed education, training, or competency evaluations for Foley or coude catheter management. Not for any nurse. Not for any year.
A coude catheter is used specifically when a standard catheter cannot pass through the urethra, typically because of an enlarged prostate or urinary obstruction. The curved tip allows it to navigate anatomy that would block a straight catheter. For a man with Resident 9's diagnoses, it was the device standing between him and the ability to urinate at all. When it became obstructed, it was not a minor inconvenience to be deferred until a more convenient shift. Urinary obstruction causes pain. It causes bladder distension. It causes infection. It is the kind of thing that requires someone who knows what they are doing, and it requires that person promptly.
Employee 2 did not know what she was doing with this particular device. That is not a criticism of her alone. The facility had not made sure she would. It had not made sure any of them would.
Inspectors cited the violation as causing minimal harm or potential for actual harm, and noted that some residents were affected. The citation references Pennsylvania staffing development standards.
What the record does not contain is any indication that Highland Manor, before a complaint triggered this inspection, had identified the gap itself.
The man whose catheter blocked in the night waited until morning. Whether that wait caused him harm beyond the hours themselves, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Highland Manor Rehabilitation and Nursing Center from 2026-05-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 12, 2026 · Our methodology
HIGHLAND MANOR REHABILITATION AND NURSING CENTER in EXETER, PA was cited for violations during a health inspection on May 27, 2026.
The curved-tip device was listed on his care plan.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.