Redstone Highlands Health Care

Inspectors wroteBased on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for three of 30 residents reviewed (Residents 4, 5, 11).

Inspectors wroteBased on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to maintain the dignity of one of 30 residents reviewed (Resident 100) who had an indwelling urinary catheter.

Inspectors wroteBased on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to ensure a resident's medication regimen was free from unnecessary psychotropic medications and that non-pharmacological interventions and informed consent were implemented prior to initiation of an antipsychotic medication for one of 30 residents reviewed for unnecessary medications (Resident 2).

Inspectors wroteBased on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's baseline care plan included information regarding the resident's immediate care needs for two of 30 residents reviewed (Residents 100 and 105).

Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for two of 30 residents reviewed (Residents 5 and 42).

Inspectors wroteBased on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to notify the physician of a change in condition and obtain physicians orders for one of 30 residents reviewed (Resident 2).

Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice, by failing to follow physician's orders after a change in condition for one of 30 residents reviewed (Resident 54).

Inspectors wroteBased on facility policy, clinical record reviews and staff interviews, it was determined that the facility failed to ensure that an anticoagulant medication was held per physician's orders for one of 30 residents reviewed (Resident 3).

Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that laboratory specimens were obtained as ordered by the physician for one of 30 residents reviewed (Resident 3).

Inspectors wroteBased on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Inspectors wroteBased on review of established infection control guidelines, facility policy, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 30 residents reviewed (Resident 5).

Inspectors wroteBased on review of residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident received pneumococcal immunizations for one of 30 residents reviewed (Residents 16).

Inspectors wroteBased on review of policies, investigation reports, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of four residents reviewed (Residents 3), resulting in a fracture. This deficiency is being cited as Past Non-Compliance. The facility's policy for Abuse Prohibition dated July 11, 2025, indicated that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The facility's policy for Using the Kardex in PCC: [...]

Inspectors wroteBased on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's environment remained free of accident hazards by failing to ensure care-planned interventions were in place for one of four residents reviewed (Resident 3) who required assistance with transferring from a bed to a chair. This deficiency is being cited as Past Non-Compliance.

Inspectors wroteBased on review of policies, manufacturer's operations manual, clinical records, and facility reports, as well as staff interviews, it was determined that the facility failed to ensure residents' environment remained free of accident hazards, and failed to ensure adequate interventions and supervision to prevent elopements which threatened the resident's safety and increased the resident's risk for accidents and bodily injury or harm for one of three residents identified at risk for elopement (Resident 3). The facility further relied on it's alarm system to prevent unsupervised exits, which placed residents in immediate jeopardy of the likelihood of serious bodily injury, harm or death. This deficiency was cited as past non-compliance.

Inspectors wroteBased on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for one of four residents reviewed (Resident 2) resulting in a critically abnormal blood clotting time.

Inspectors wroteBased on review of clinical records and job descriptions, as well as staff interviews, it was determined that the facility failed to follow pressure ulcer treatment recommendations from a wound consultation for one of four residents reviewed (Resident 3).

Inspectors wroteBased on review of facility policy, review of clinical records, and interview with staff, it was determined that the facility failed to provide pharmaceutical services to ensure accurate receiving, dispensing and administration of medication to meet the needs of a resident for one of four residents reviewed (Resident 2). A facility policy for Medication Administration dated July 11, 2025, indicated that medications are administered as prescribed in accordance with Manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. [...]

Inspectors wroteBased on review of policies, investigative reports, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to follow a resident's care plan for assisting with Activities of Daily Living (ADL's) and preventing falls for one of three residents reviewed (Resident 1), resulting in a fall and fracture for the resident.

Inspectors wroteBased on review of clinical records and investigative reports, as well as staff interviews, it was determined that the facility failed to ensure that staff implemented care-planned interventions for one of three residents reviewed (Resident 1) who was identified as a fall risk, resulting in a fall with fracture for the resident.

Inspectors wroteBased on review of the investigation reports and residents' clinical records, as well as staff interviews, it was determined that the facility failed to maintain a safe environment for one of three residents reviewed (Resident 1) resulting in a fall with fracture.

Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for three of 38 residents reviewed (Residents 15, 70, 95).

Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications for three of 38 residents reviewed (Residents 4, 28, 36).

Inspectors wroteBased on review of policies, observations, and staff interviews, it was determined that the facility failed to ensure that food was prepared and served under sanitary conditions, in accordance with professional standards for food service safety.

Inspectors wroteBased on review of hospice contracts, facility policies, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for one of 38 residents reviewed (Resident 35) who received hospice services.

Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to investigate injuries of unknown origin to rule out abuse or neglect for one of 38 residents reviewed (Resident 24) who suffered an ankle fracture.

Inspectors wroteBased on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for one of 38 residents reviewed (Resident 55) and failed to complete accurate discharge Minimum Data Set assessments for two of 38 residents reviewed (Residents 69, 96).

Inspectors wroteBased on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's baseline care plan included information regarding the resident's immediate care needs for three of 38 residents reviewed (Residents 89, 94, 95).

Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for two of 38 residents reviewed (Residents 40, 55).

Inspectors wroteBased on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for one of 38 residents reviewed (Resident 73).

Inspectors wroteBased on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify a provider's orders for one of 38 residents reviewed (Resident 48).

Inspectors wroteBased on review of manufacturer's instructions, facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were stored in a secure manner, failed to ensure that medications were appropriately secured in one of two medication carts reviewed (first floor medication cart 1), failed to store unopened and unused multi-dose containers of insulin according to manufacturer's instructions for one of 38 residents reviewed (Resident 76), and failed to ensure that refrigerated controlled medications were stored in a separately-locked, permanently-affixed container in one of two medication refrigerators reviewed (first floor medication room refrigerator).

Inspectors wroteBased on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed during the administration of a treatment for one of 38 residents reviewed (Residents 48).

Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and legal guardian in writing regarding the reason for hospitalization for five of 38 residents reviewed (Residents 28, 39, 40, 48, 69).

Inspectors wroteBased on review of facility policies, resident interviews, observations, and staff interviews, it was determined that the facility failed to serve food items at palatable temperatures.

Inspectors wroteBased on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's physician was notified in a timely manner about a change in condition for one of 25 residents reviewed (Resident 40).

Inspectors wroteBased on observations, as well as resident and staff interviews, it was determined that the facility failed to provide comfortable air temperatures on the second-floor dining/activity room.

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a comprehensive annual Minimum Data Set assessment was completed in the required time frame for two of 25 residents reviewed (Residents 11, 52).

Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to develop an individualized care plan for exit-seeking behavior for one of 25 residents reviewed (Resident 30).

Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 25 residents reviewed (Residents 8, 20).

Inspectors wroteBased on review of policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to provide appropriate care for one of 25 residents reviewed (Resident 8) who had an indwelling urinary catheter.

Inspectors wroteBased on a review of the facility's policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that there were timely re-weighs, physician notification, and intervention for one of 25 residents reviewed (Resident 320) who had a significant weight loss.

Inspectors wroteBased on review of the facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure the physician's order for oxygen was followed for one of 25 residents reviewed (Resident 10).

Inspectors wroteBased on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Inspectors wroteBased on review of clinical records and facility investigation reports, as well as staff interviews, it was determined that the facility failed to safely transfer one of two residents reviewed (Resident 1) who required staff assistance for transfers, resulting in the resident sliding to the floor.