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Complaint Investigation

Highland Manor Rehabilitation And Nursing Center

May 27, 2026 · Exeter, PA · 750 Schooley Avenue
Citations 2
CMS Rating 2/5
Beds 120
Provider ID 395566
Healthcare Facility
Highland Manor Rehabilitation And Nursing Center
Exeter, PA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

HIGHLAND MANOR REHABILITATION AND NURSING CENTER in EXETER, PA — inspection on May 27, 2026.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0658
Resident Assessment and Care Planning Deficiencies

policies.28 Pa.

Code 211.12 (d)(1)(3)(5) Nursing services.

395566 05/27/2026

Highland Manor Rehabilitation and Nursing Center 750 Schooley Avenue Exeter, PA 18643

During the interview, the DON stated Employee 2 reported she was not comfortable changing the resident's coude catheter due to lack of familiarity and experience with that type of catheter.

Employee 2 did not notify the RN supervisor or seek assistance to ensure timely catheter intervention for the resident.

Review of the facility documentation titled Skilled Nursing Competency Training revealed a list of competencies for licensed practical nurses.

The list included nephrostomy tube (a thin, flexible catheter inserted through the skin of the lower back directly into the kidney to drain urine) and suprapubic catheters (a flexible medical tube surgically inserted directly into the bladder through a small incision in the lower abdomen that continuously drains urine); however, the facility did not include competency training, return demonstration, or skills validation for Foley catheter insertion, Foley catheter management or the more specialized, coude catheter care and replacement.

During interviews on May 27, 2026, between 2:10- 2:30 PM, four licensed nurses employed by the facility (Employees 1, 3, 4, and 5) stated they had received general catheter education during nursing school and had prior experience with coude catheters at previous employers.

However, all four nurses reported the facility had not provided facility-specific education, training, competency evaluation or skills validation related to the care, evaluation, insertion, replacement or management of coude catheters.

During an interview on May 27, 2026, at 2:45 PM, the DON was unable to provide documented evidence that the facility ensured licensed nursing staff completed education, training, competency evaluations, or demonstrated proficiency for Foley catheter care or specialized coude catheter management.

Refer F65828 Pa Code 201.20(a)(6)(d) Staff development.

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.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.