Highland View Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Brockway, Pennsylvania.
- Location
- 90 Main Street, Brockway, Pennsylvania 15824
- CMS Provider Number
- 395877
- Inspections on file
- 17
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Highland View Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
The facility did not meet the required nurse aide staffing ratios, failing to provide the minimum number of NAs per residents during specific shifts. On certain days, the number of NAs working was below the required level based on the resident census, as confirmed by the Nursing Home Administrator.
The facility did not meet the required LPN staffing levels during the overnight shift on two occasions. With a census of 36 residents, the facility had insufficient LPN coverage, with only 0.16 and 0.88 LPNs working when 1.00 was required. This was confirmed by the Nursing Home Administrator.
A facility failed to assess a resident for self-administration of medications, as required by policy. The resident, with conditions including asthma, was observed with a Ventolin inhaler on the bedside table without a self-administration assessment or physician's order. The resident's clinical record lacked documentation supporting the self-administration of the inhaler, despite having a physician's order for its use as needed.
The facility failed to date and store medications properly in the medication storage room. An opened vial of PPD, used for tuberculosis skin testing, was found without an opened date. The drug manufacturer leaflet indicates that such a vial should be discarded after 30 days. An LPN confirmed the vial was undated, and the DON confirmed it should have been marked with an opened date.
The facility did not maintain smoke barrier doors as required, with the west wing fire door's left leaf failing to latch properly. This was confirmed by the maintenance director.
A hand sanitizer dispenser was improperly installed directly over an electrical outlet in the main floor corridor near the resident lounge/dining room, violating NFPA 101 standards. The maintenance director confirmed this deficiency.
The facility did not maintain electrical receptacles according to NFPA 101 standards, lacking GFCI protection in the employee lounge water cooler and resident laundry washing machine. This was confirmed by the maintenance director.
Nurse Aide Staffing Shortages
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios as per the regulation effective July 1, 2024. Specifically, the facility did not maintain the minimum staffing levels of one NA per 10 residents during the day shift on April 2, 2025, one NA per 11 residents during the evening shift on March 30, 2025, and one NA per 15 residents during the overnight shift on March 30, April 5, and April 6, 2025. The staffing documents revealed that on these dates, the number of NAs working was below the required number based on the resident census. For instance, on April 2, 2025, with a census of 41 residents, only 3.73 NAs worked when 4.10 were required. Similarly, on March 30, 2025, during the evening shift, 3.40 NAs worked for 39 residents when 3.55 were required. The overnight shift on March 30, 2025, had 2.47 NAs for 39 residents when 2.60 were required. The Nursing Home Administrator confirmed these staffing shortages during an interview on April 14, 2025.
Plan Of Correction
*No residents were found to be negatively affected by failing to meet the nurse aide ratios. *Residents will be visually monitored each shift by the RN supervisor to ensure the residents are receiving quality care. *Scheduler, RN Supervisors, Director of Nursing and Assistant Director of Nursing will be educated on the proper Nurse Aide ratios for each shift. *Daily staffing sheets and the biweekly schedule will be reviewed by the Administrator, Director of Nursing, and Scheduler Monday-Friday to assure that proper nurse aide ratios are being met. This is an ongoing process that has no end date. *Job ads are posted on Indeed and active hiring is occurring. *Admin nursing and scheduler who is a nurse aide fill in for open shifts when call-offs occur. Nurse aides who are currently working are asked to stay into another shift and those who are not on the schedule are called to come in. *Staff who call off are given progressive discipline so they understand the importance of calling off for their scheduled shifts. *Staffing ratios will be reviewed at Quality Assurance Process Improvement meetings.
LPN Staffing Shortages During Overnight Shift
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) during the overnight shift on two specific days. On 4/04/25 and 4/06/25, the facility did not have the mandated minimum of one LPN per 40 residents. On both days, the census was 36 residents, but the facility only had 0.16 and 0.88 LPNs working, respectively, when 1.00 LPN was required. This deficiency was confirmed by the Nursing Home Administrator during an interview on 4/14/25.
Plan Of Correction
*No residents were found to be negatively affected by failing to meet the licensed practical nurse ratios. *Residents will be visually monitored each shift by the RN supervisor to ensure the residents are receiving quality care. *Scheduler, RN Supervisors, Director of Nursing and Assistant Director of Nursing will be educated on the proper licensed practical nurse ratios for each shift. *Daily staffing sheets and the biweekly schedule will be reviewed by the Administrator, Director of Nursing, and Scheduler Monday-Friday to assure that proper nurse aide ratios are being met. This is an ongoing process that has no end date. *Job ads are posted on Indeed and active hiring is occurring. *Admin nursing fill in for open shifts when call-offs occur. Licensed practical nurses and registered nurses who are currently working are asked to stay into another shift and those who are not on the schedule are called to come in. *Staff who call off are given progressive discipline so they understand the importance of calling off for their scheduled shifts. *Staffing ratios will be reviewed at Quality Assurance Process Improvement meetings.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for self-administration of medications, specifically for Resident R19, who was observed with a Ventolin HFA Inhalation Aerosol Solution on the bedside tray table. The facility's policy requires an interdisciplinary team to determine if self-administration is clinically appropriate and safe, which includes assessing the resident's ability to understand medication labels, comprehend dosage and administration, and recognize risks. However, Resident R19's clinical record lacked a self-administration assessment or a physician's order to keep the inhaler at the bedside, despite having a physician's order for its use as needed for shortness of breath or wheezing. Resident R19, who has diagnoses including anxiety, asthma, and muscular dystrophy, stated during interviews that the inhaler was always on the bedside table and had not been used in a long time. The Nursing Home Administrator confirmed the absence of a self-administration assessment and order in the resident's clinical record. This oversight indicates a failure to adhere to the facility's policy on self-administration of medications, as required by the relevant state codes.
Failure to Date and Store Medications Properly
Penalty
Summary
The facility failed to appropriately date and store medications in the medication storage room. During an observation, a vial of Purified Protein Derivative (PPD), used for tuberculosis skin testing, was found opened without an opened date marked on it. According to the drug manufacturer leaflet, a vial of Tubersol should be discarded after 30 days of use. At the time of the observation, an LPN confirmed that the PPD vial was opened and undated, and the Director of Nursing later confirmed that the vial should have been marked with an opened date to ensure it would be discarded after 30 days of use.
Failure to Maintain Smoke Barrier Doors
Penalty
Summary
The facility failed to maintain, inspect, and test smoke barrier doors as required by regulations. During an observation on February 13, 2025, it was noted that the west wing fire door, specifically the left leaf of the double door, did not latch properly in the frame. This deficiency was confirmed during an interview with the maintenance director on the same day.
Plan Of Correction
Maintenance Director will be educated that fire doors need to latch into the frame when the door closes. Maintenance Director will repair the fire door on the west wing so that it latches into the frame when it closes. Maintenance Director or designee will audit all of the fire doors in the building once a week x 4 weeks and monthly x 4 months to assure that they latch properly when closed.
Non-compliant Installation of Hand Sanitizer Dispenser
Penalty
Summary
The facility failed to maintain compliance with the NFPA 101 standards for alcohol-based hand rub dispensers. During an observation, it was noted that a hand sanitizer dispenser was installed directly over an electrical outlet in the main floor corridor near the resident lounge/dining room. This installation does not meet the requirement that dispensers should not be installed within 1 inch of an ignition source. The maintenance director confirmed this deficiency during an interview conducted at the time of the observation.
Plan Of Correction
Maintenance Director will be educated that hand sanitizer dispensers cannot be mounted on walls directly over electrical outlets. Maintenance Director will move the hand sanitizer dispenser so it is not directly over an electrical outlet. Maintenance Director will audit the other hand sanitizer dispensers in the facility to assure they are not mounted on walls directly over electrical outlets.
Deficiency in Electrical Receptacle Maintenance
Penalty
Summary
The facility failed to maintain electrical receptacles in compliance with NFPA 101 standards, specifically regarding ground fault circuit interrupter (GFCI) protection. During an observation conducted on February 12, 2025, it was noted that two areas lacked the required GFCI protection: the employee lounge water cooler and the resident laundry washing machine. This deficiency was confirmed through an interview with the maintenance director on February 13, 2025.
Plan Of Correction
Maintenance Director will be educated that electrical appliances which utilize water are plugged into only approved GFCI outlets. Maintenance Director will replace existing receptacles in the laundry room and employee break room with approved GFCI outlets. Maintenance Director or designee will audit other rooms to assure that electrical appliances that utilize water are plugged into only approved GFCI outlets.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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