Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Highland View Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
Housekeeping services were not provided to maintain a clean environment in five resident rooms. Observations found items and debris on floors, food crumbs, a bedpan, a used tissue, a hairbrush, and a clear plastic cup left in rooms, along with a built-up black substance around toilet bases; one room also had fall mats with scattered dry white substance and dark brown substance that appeared to be feces. The NHA confirmed the conditions remained present.
Failure to provide bed-hold notice and transfer information: The facility did not document that two residents and/or their representatives received the required written bed-hold policy when they were transferred to the hospital, and it also lacked evidence that necessary clinical information was communicated to the receiving provider. The DON confirmed the missing documentation for both residents, who had diagnoses including COPD, diabetes, chronic respiratory failure, HTN, and OSA.
MDS assessments were coded inaccurately for two residents. One resident with diabetes received Mounjaro, a non-insulin weekly injection, yet the MDS coded injections and insulin use incorrectly on quarterly assessments. Another resident with Duchenne muscular dystrophy, schizoaffective disorder, and seizures had a positive PASRR Level I screen and Level II approval, but the annual MDS incorrectly coded Section A1500 as No for serious mental illness and/or ID/DD-related condition.
A resident with Down Syndrome, seizures, and a PEG tube had physician orders for tube site care, flushing, and medication administration via mouth or PEG, but the care plan had only a resolved tube-feeding goal and no current PEG-related goals or interventions. The DON confirmed the resident should have a care plan for the PEG tube and related orders, but the record lacked evidence of one.
The facility failed to document a clinical rationale for continued PRN psychotropic use beyond 14 days, failed to show non-pharmacological interventions were tried before PRN Ativan was given, and failed to show GDR evidence or a clinical contraindication for two residents. One resident with anxiety and altered mental status received repeated PRN Ativan doses without documented non-pharmacological attempts, and another resident with stroke, dementia, and weakness had PRN lorazepam for seizures plus scheduled Ativan without documented GDR support.
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.
Housekeeping Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to provide housekeeping services necessary to maintain a clean environment in five of 27 resident rooms, including rooms 2, 3, 5, 8, and 12. Facility policies dated 1/02/26 stated that staff were expected to dust mop floors, sweep trash and debris to the door, empty and clean trashcans, wet mop rooms, disinfect and clean all parts of toilets, damp mop restrooms, and clean and disinfect reusable equipment as frequently as necessary or when visibly soiled. Observations on 2/10/26 and 2/11/26 found multiple items and soiling in the affected rooms, including a tube of Chapstick, an alcohol pad, a salt wrapper, clear ointment in a medicine cup, a white hairbrush under a bathroom sink, clear plastic lids, food crumbs, a bedpan on the bathroom floor, a clear plastic cup, a used tissue behind a bathroom trashcan, and fall mats with scattered dry white substance and scattered dark brown substance that appeared to be feces. The observations also noted a built-up black substance around toilet bases in several rooms. During interview, the Nursing Home Administrator confirmed the observed conditions remained present in the rooms.
Failure to Provide Bed-Hold Notice and Transfer Information
Penalty
Summary
The facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy, including how long a bed can be held during a leave of absence and the cost per day, and failed to ensure that necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for two residents. Facility policy stated that notice of the bed-hold and return policies is to be provided within 24 hours of an emergency transfer, and that transfer information should include practitioner contact information, resident representative contact information, advance directive information, special instructions and precautions, care plan goals, resident status, diagnoses, allergies, medications, and relevant labs. Resident R1, admitted with COPD, diabetes, and chronic respiratory failure, had a progress note indicating transfer to the hospital, but the clinical record lacked evidence that necessary clinical information was communicated to the receiving provider and lacked evidence that the resident and/or representative received a copy of the bed-hold policy upon transfer. Resident R44, admitted with diabetes, hypertension, and obstructive sleep apnea, also had a progress note indicating transfer to the hospital, but the clinical record similarly lacked evidence that necessary clinical information was communicated to the receiving provider and lacked evidence that the resident and/or representative received a copy of the bed-hold policy upon transfer. The DON confirmed both records lacked this documentation and that the information and bed-hold policy should have been provided at the time of transfer.
Inaccurate MDS Coding for Medication and PASRR-Related Resident Status
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected resident status for two residents. For Resident R27, who was admitted with diagnoses including diabetes, multiple sclerosis, and high blood pressure, the quarterly MDS with an ARD of 11/3/25 coded section N0300 for injections as 7 days and section N0350 for insulin injections as 7 days. A later quarterly MDS with an ARD of 2/2/26 coded section N0350 as 1 day. Review of physician orders from 8/21/25 through 2/28/26 showed the resident received Mounjaro, which is a weekly injection used to help control blood sugar levels but is not insulin. During interview, the RNAC confirmed the 11/3/25 MDS should have coded N0300 as 1 and N0350 as 0, and the 2/2/26 MDS N0350 should have been coded as 0. For Resident R40, who had diagnoses including Duchenne muscular dystrophy, schizoaffective disorder bipolar type, and seizures, the clinical record also showed a positive Level I PASRR screen with a required Level II evaluation completed and a Level II letter indicating nursing facility placement was appropriate. The annual MDS, however, coded Section A1500 as No, indicating the resident did not have a serious mental illness and/or ID/DD or related condition. During interview, the RNAC confirmed that the annual MDS Section A1500 was coded incorrectly for Resident R40.
Incomplete Care Plan for PEG Tube Needs
Penalty
Summary
The facility failed to review and revise a comprehensive care plan to reflect the current care and services for one resident reviewed. Facility policy stated that comprehensive, person-centered care plans are to include measurable objectives and timetables to meet each resident’s physical, psychosocial, and functional needs, and that care plans are revised as resident information and conditions change. The resident had an admission date of 11/5/24 and diagnoses that included Down Syndrome, seizures, and a PEG tube. The resident’s physician orders dated 11/20/25 included enteral tube site care with soap and water and split gauze daily and as needed, flushing the PEG tube with water every shift for patency, flushing before and after medications and between medications every shift, and allowing medications to be given by mouth when accepted or via PEG tube if refused. The resident’s care plan showed a goal related to tube feeding complications that was resolved on 7/15/25, but it lacked any current goals or interventions related to the PEG tube or the related orders. During interview, the DON confirmed the resident should have a care plan for the PEG tube and related orders and that the clinical record lacked evidence of one being in place.
Unjustified PRN Psychotropic Use and Missing GDR Evidence
Penalty
Summary
The facility failed to provide a clinical rationale for continued use of PRN psychotropic medication beyond 14 days, failed to show that non-pharmacological interventions were attempted before PRN psychotropic administration, and failed to show evidence of gradual dose reductions or a clinical contraindication for two residents. The facility policy dated 1/2/26 stated that non-pharmacological approaches are used unless contraindicated, PRN psychotropic orders are limited to 14 days, and residents on psychotropic medications receive GDRs unless clinically contraindicated. Resident R35 was admitted on 11/21/25 with diagnoses including anxiety and altered mental status. A physician order dated 1/5/26 directed Ativan 0.5 mg by mouth every 12 hours PRN for anxiety, but the record lacked the required clinical rationale for use beyond 14 days. The MAR showed PRN Ativan administrations on 1/5, 1/7, 1/8, 1/15, 1/18, 1/28, 1/29, 1/31, 2/1, 2/6, and 2/11, and the record lacked evidence of non-pharmacological interventions before the eight January administrations and three February administrations. Resident R13 was admitted on 5/23/22 with diagnoses including stroke with right-sided paralysis, mood disorder, dementia, and muscle weakness. The record contained an order dated 4/16/25 for lorazepam 0.5 mL under the tongue every four hours PRN for seizures without the required clinical rationale for continued use beyond 14 days, and an order dated 5/10/25 for Ativan 1 mg by mouth daily without evidence of a GDR or a clinical contraindication for dose reduction.
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.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 118 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
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Nursing homes near Brockway
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Christ The King Manor | 8.6 mi | ★★★★★ | 4 | 0 |
| Dubois Nursing Home | 9.9 mi | ★★★★★ | 22 | 0 |
| Dr Arthur Clifton Mckinley Ctr | 16.6 mi | ★★★★★ | 4 | 0 |
| Pinecrest Manor | 17 mi | ★★★★★ | 3 | 0 |
| Elk Haven Nursing Home | 17 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.