Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

HIGHLAND MANOR REHABILITATION AND NURSING CENTER

EXETER, PA · 120 certified beds · Last Life Safety survey December 19, 2024

CMS Certification Number 395566 · first certified February 1983

Ownership

Operated by CONTINUUM HEALTHCARE · Non profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within PA

18 citations — more than 78% of the 656 certified nursing homes in PA. Compared within PA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 7 citations; the earlier surveys in the window averaged 5.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (October 2025 to December 2025), and past the point by which nine in ten PA facilities have been surveyed. This facility’s last Life Safety survey was December 2024. Facilities in PA are typically surveyed 10–12 months after the last one (median 11), measured over 1,113 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

2 of the 18 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 18 Life Safety citations above. The Physical Environment Index

F-0584 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.
F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in PA, and nationally. Surveyors differ markedly between states, so the PA figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	18
Median facility in PA	10
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
February 24, 2023	6
January 10, 2024	5
December 19, 2024	7

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	2	2024-12-19
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	2	2024-12-19
K-0363	Install corridor and hallway doors that block smoke.	2	2024-01-10
K-0712	Have simulated fire drills held at unexpected times.	2	2024-12-19
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	1	2024-12-19
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	1	2024-12-19
E-0007	Address patient/client population and determine types of services needed.	1	2024-01-10
K-0353	Inspect, test, and maintain automatic sprinkler systems.	1	2024-12-19

What the citations cover

Citations by CMS category

Smoke Deficiencies 7
Miscellaneous Deficiencies 5
Gas, Vacuum, and Electrical Systems Deficiencies 2
Emergency Preparedness Deficiencies 2
Other 2

Citations by CMS category
Category	Citations
Smoke Deficiencies	7
Miscellaneous Deficiencies	5
Gas, Vacuum, and Electrical Systems Deficiencies	2
Emergency Preparedness Deficiencies	2
Egress Deficiencies	2

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

December 19, 2024 — 7 citations

Citations issued on December 19, 2024
Tag	What the surveyor checks	Status
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (January 14, 2025)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (January 14, 2025)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (January 14, 2025)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (January 14, 2025)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (January 14, 2025)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (January 14, 2025)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (January 14, 2025)

January 10, 2024 — 5 citations

Citations issued on January 10, 2024
Tag	What the surveyor checks	Status
E-0006	Conduct risk assessment and an All-Hazards approach.	Deficient, Provider has date of correction (March 5, 2024)
E-0007	Address patient/client population and determine types of services needed.	Deficient, Provider has date of correction (March 5, 2024)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (March 5, 2024)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (March 5, 2024)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (March 5, 2024)

February 24, 2023 — 6 citations

Citations issued on February 24, 2023
Tag	What the surveyor checks	Status
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (March 31, 2023)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (March 31, 2023)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (March 31, 2023)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (March 31, 2023)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (March 31, 2023)
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	Deficient, Provider has date of correction (March 31, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.