Highland Manor Rehabilitation And Nursing Center
Inspection Findings
F-Tag F0584
F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Based on observation and staff interview, it was determined that the facility failed to maintain a clean and orderly environment in the facility laundry department and the second hallway ice machine. Findings include: An observation of the second hallway, resident unit ice machine, located in the hallway was noted with no airgap. An air gap is defined as the unobstructed vertical space between the end of a water supply or drainage pipe and the flood level of a fixture or drain. In an ice machine, the air gap prevents contaminated water from backing up into the potable (drinkable) water supply or the ice that residents consume. The importance of the air gap is to prevent cross-contamination, which occurs when dirty water or substances can enter and contaminate clean water or ice. Without an air gap, residents are at risk of exposure to harmful bacteria or other contaminants.Water was observed draining directly into the floor drainpipe. The floor underneath the drainage pipe, extending from the front of the ice machine to the drainpipe, contained a thick layer of sticky black material. An observation on September 12, 2025, at 11:30 A.M. in the facility laundry department dirty room (the area used for handling soiled laundry) revealed two slop sinks with clumps of lint and debris inside them, both filled with plastic hangers and a plastic bag containing soiled wheelchair/lift belts. The faucet was leaking water. A dirty mop bucket containing plastic garbage, mop covers, broken mops, and a plastic container were on the floor. An open, overflowing garbage can was present. Behind the washing machines, the floor contained plastic, paper, dirty used gloves, and clumps of lint. The floor had a buildup of a sticky black substance around the perimeter. The exhaust fan had a heavy buildup of lint and dirt. Additional items noted included open plastic bags of floor mats on the floor between the washing machines, two bags of dirty clothing on the floor, a floor cleaning machine placed in front of the washing machines, and a ripped, dirty fall mat propped against the wall. In
the clean area (the side with dryers, folding tables, carts, and clothing racks), the garbage can was overflowing. The floor had visible dirt, dried liquid stains, and used plastic gloves scattered throughout. A large pile of lint was on the floor in front of a dryer. The windowsill, dryer exhaust tubing, wall exhaust fan, and door hinges all had a heavy buildup of lint. Clean linen and clothing racks contained mechanical lift pads that were in direct contact with the floor. A dirty washcloth was also observed on the floor. These
observations were confirmed with the Nursing Home Administrator at the time of the survey. The facility failed to ensure that both the ice machine and laundry areas were maintained in a sanitary and orderly condition, placing residents at risk for cross-contamination, exposure to environmental contaminants, and a diminished homelike environment.28 Pa. Code 201.14 (a) Responsibility of licensee.28 Pa Code 201.18 (b)(1)(3) Management
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
Event ID:
HIGHLAND MANOR REHABILITATION AND NURSING CENTER in EXETER, PA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in EXETER, PA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from HIGHLAND MANOR REHABILITATION AND NURSING CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.