Redstone Highlands Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Greensburg, Pennsylvania.
- Location
- 6 Garden Center Drive, Greensburg, Pennsylvania 15601
- CMS Provider Number
- 396021
- Inspections on file
- 25
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at Redstone Highlands Health Care during CMS and state inspections, most recent first.
A resident with dementia and significant mobility deficits, care planned for two-person assistance with transfers, was transferred by a CNA alone, who did not review the Kardex or care plan and believed the resident was a one-person assist. During the transfer the resident complained of leg pain, and later developed redness, warmth, swelling, and pain in the knee. Nursing and physician assessments documented these findings, and imaging confirmed a nondisplaced patella fracture. The facility’s investigation and staff interviews determined that the CNA routinely did not access Kardex information and failed to follow the resident’s transfer interventions, resulting in substantiated neglect.
A resident with dementia and decreased mobility, care-planned for 2-person assistance with bed-to-chair transfers, was transferred by a single CNA who did not review the Kardex or know how to access it, believing the resident was a 1-assist transfer. During and after the transfer, the resident complained of leg pain, and later exhibited redness, warmth, and swelling of the knee. Physician evaluations and imaging identified a nondisplaced patella fracture, and the facility’s investigation substantiated neglect related to failure to follow the care-planned transfer interventions.
A resident with dementia and a history of wandering was able to exit the facility unsupervised when the Wander Guard alarm system failed to function due to a low battery. Staff did not recognize the event as an elopement, did not notify administration promptly, and did not check or replace the device after the resident was returned by EMS, resulting in a deficiency related to inadequate supervision and accident hazard prevention.
A resident with moderate cognitive impairment and heart failure was given warfarin instead of rosuvastatin for several days due to a pharmacy labeling error. The error was discovered after the resident's INR was found to be critically high, and although the pharmacy was notified, there was no documentation that the facility checked for similar errors in other medication cards.
A resident with cognitive impairment and a history of atherosclerotic heart disease developed a pressure ulcer on the left heel. Although a wound care consultant recommended treatment with skin prep and a bordered foam dressing, the facility did not update the wound care orders to include the foam dressing. As a result, the recommended treatment was not provided, and the wound progressed to a Stage 3 pressure ulcer.
A resident with cognitive impairment and heart failure was administered coumadin instead of the prescribed rosuvastatin calcium for several days due to a pharmacy packaging error. The medication card was mislabeled, and the error was only discovered after the resident had already received the incorrect medication, resulting in abnormal lab findings and physician notification.
A resident with morbid obesity and a history of falls, who required two-person assistance for bed mobility, was being cared for by a single nurse aide during in-bed care. While being changed, the resident reached for an item and rolled out of bed, resulting in a hip fracture. The incident was determined to be neglect due to failure to follow the resident's care plan.
A resident with morbid obesity and decreased mobility, care planned for two-person assistance with bed mobility, was assisted by only one nurse aide during in-bed care. While being changed, the resident reached for an item and fell from bed, sustaining a right hip fracture. The aide did not follow the care plan, leading to the fall and injury.
A resident with morbid obesity and decreased mobility, who required two-person assistance for bed mobility, was assisted by only one nurse aide during in-bed care. While being repositioned, the resident reached for an item and fell from bed, sustaining a right hip fracture. The aide did not follow the care plan, leading to the incident.
The facility failed to follow physician's orders for medication administration and weight monitoring for three residents. A resident received Labetalol despite a low heart rate, and two residents experienced significant weight gains without physician notification.
The facility failed to maintain accountability for controlled medications for three residents. One resident's records lacked evidence of Fentanyl patch destruction, while two others had discrepancies between controlled drug records and medication administration records for Oxycodone/Tylenol and Percocet. The Nursing Home Administrator confirmed the documentation issues.
The facility did not maintain sanitary conditions in food service areas. Observations revealed several food items in the main kitchen were open to air and undated, contrary to facility policy. Additionally, a Nurse Aide entered the kitchenette without a hairnet, violating the requirement for hair restraints. These issues were confirmed by the Executive Chef and Nursing Home Administrator.
A facility failed to ensure that a designated interdisciplinary team member obtained required information from a hospice provider for a resident receiving hospice services. The resident had a Stage 3 pressure ulcer, and the care plan required weekly documentation of wound treatment and measurements. However, there was no evidence of these assessments being completed for several weeks. The DON confirmed that hospice was responsible for the wound care but did not provide documentation.
A resident with an ankle fracture did not receive a thorough investigation into the injury's cause, as required by facility policy. The DON concluded the investigation after the resident denied abuse, but there was no documentation ruling out neglect. This resulted in a deficiency for failing to meet regulatory requirements for investigating injuries of unknown origin.
The facility failed to accurately complete MDS assessments for three residents. One resident's assessment did not reflect the administration of prescribed medications, while two others had incorrect discharge statuses recorded. These discrepancies were confirmed through staff interviews and a review of clinical records.
The facility failed to develop baseline care plans for three residents, omitting necessary information regarding their immediate care needs. One resident required a feeding tube, another had a Foley catheter, and a third was on anticoagulant and diuretic medications. Interviews confirmed the absence of these care plans, which were supposed to include Enhanced Barrier Precautions (EBP) as per facility policy.
The facility failed to develop comprehensive care plans for two residents, one with a colostomy and another with diabetes requiring a continuous glucose monitoring system. The lack of documented care plans for these specific needs was confirmed by the Nursing Home Administrator.
A facility failed to update a resident's care plan after the completion of antibiotic therapy for pneumonia. The resident, who was cognitively intact and required assistance for daily care needs, had a care plan that was not revised to reflect the end of the antibiotic treatment. This was acknowledged by the Nursing Home Administrator, despite the facility's policy requiring care plans to be updated as needed.
A facility failed to clarify a provider's orders for a resident's wound care, resulting in a deficiency. The resident, with a history of hip fracture, diabetes, and dementia, had inconsistent orders for heel wound care. Verbal orders from the wound consultant differed from written assessments, leading to confusion in treatment frequency. This inconsistency violated professional standards of quality care.
The facility failed to securely store medications, with an unlocked medication cart accessible to unauthorized individuals and loose pills found in a drawer. An unopened insulin pen for a resident was improperly stored in the cart instead of the refrigerator. Additionally, a box containing controlled medication was not permanently affixed in the refrigerator, allowing it to be removed.
A facility failed to follow infection control practices during wound care for a resident with pressure ulcers. The resident, who required assistance for daily care, did not have enhanced barrier precautions (EBP) in place, and a nurse did not perform hand hygiene between glove changes or wear a gown as required. The Nursing Home Administrator confirmed these lapses in protocol.
The facility failed to provide written notification to residents and their responsible parties regarding the reasons for hospital transfers, affecting five residents. These residents, with various medical conditions, were transferred to the hospital without the required written notice, as confirmed by facility administrators.
The facility failed to serve food items at palatable temperatures. Residents reported that food served in their rooms was often cold, and a food committee meeting confirmed inconsistent food temperatures. A test tray revealed that iced tea was 49 degrees F, coffee was 138 degrees F, mixed vegetables were 119 degrees F, pork was 129 degrees F, and rice was 136.2 degrees F. The Dietary Director confirmed that the food was not at an appetizing temperature.
A resident, who was cognitively impaired and at risk for dehydration due to diuretic use, refused daily weights as ordered by the physician. Despite a communication form being sent, there was no documented response from the physician, and the Director of Nursing confirmed the lack of proper notification.
The facility failed to maintain comfortable air temperatures in the second-floor dining/activity room, with residents complaining of cold conditions. The Maintenance Director confirmed the air conditioner was on, and the heat was off, making the room temperature 67 degrees Fahrenheit. Unsealed windows contributed to the cold environment.
The facility failed to complete comprehensive annual MDS assessments within the required time frame for two residents. The assessments were 35 and 25 days late, respectively, as confirmed by the DON.
A facility failed to develop an individualized care plan for a resident with cognitive impairment and exit-seeking behavior. Despite an incident where the resident attempted to leave a locked unit, no care plan was documented. The DON confirmed that a care plan should have been created.
The facility failed to update care plans for two residents. One resident's care plan included outdated medication orders, and another resident's care plan did not include new interventions after an elopement incident. The Director of Nursing confirmed these deficiencies.
A facility failed to provide appropriate catheter care for a resident with an indwelling urinary catheter, as required by the care plan and facility policy. Documentation showed missed catheter care during several shifts in March and April, confirmed by the Assistant Director of Nursing.
A resident experienced significant weight loss, but the facility failed to ensure timely re-weighs, physician notification, and intervention as per their weight management policy. Despite dietary recommendations, there was no documentation of re-weighs or notifications to the family, physician, or nutrition services director, leading to a delay in addressing the resident's weight loss.
The facility failed to follow the physician's order for oxygen administration for a resident with pulmonary fibrosis and pneumonia. The resident's oxygen flow rate was set at 7 liters instead of the prescribed 0-6 liters, as confirmed by staff interviews.
The facility's QAPI committee failed to correct recurring deficiencies related to comprehensive care plans, care plan timing and revision, and respiratory care. Despite previous plans of correction, the current survey found repeated deficiencies, indicating the QAPI committee's ineffectiveness in maintaining compliance with these regulations.
Neglect Due to Failure to Follow Two-Person Transfer Requirements
Penalty
Summary
The facility failed to protect a resident from neglect when staff did not follow the resident’s care plan and transfer requirements, resulting in a nondisplaced patella fracture. The resident had dementia, was cognitively impaired, and according to an annual MDS and care plan required substantial to maximum assistance and the assistance of two staff for transfers. Facility policy required use of the Kardex in the PCC system at the start of each shift to verify accurate information on transfer status and other care needs. Despite these requirements, a nurse aide transferred the resident alone from bed to wheelchair, believing the resident was a one-person assist and without checking the Kardex or care plan for the correct transfer status. During the transfer, the resident stated, “oh my leg,” but the aide did not observe obvious injury at that time. Later that day, the aide noticed the resident’s knee was red and reported this to the nurse. A nursing note documented that the resident complained of left knee pain with redness, warmth, and slight edema, and subsequent physician assessments noted ongoing swelling, erythema, warmth, and pain with weight-bearing. An X-ray ultimately revealed a nondisplaced patella fracture of unclear cause, as the resident reported no fall. The facility’s investigation, including interviews with the aide and leadership, confirmed that the aide had not accessed the Kardex, did not remember how to access it, and never looked at Kardexes for her residents, and that she failed to follow the resident’s care plan transfer interventions, leading to substantiated neglect associated with the injury.
Failure to Follow Care-Planned Transfer Status Resulting in Knee Fracture
Penalty
Summary
The facility failed to ensure a resident’s environment was free from accident hazards and that care-planned transfer interventions were followed. An annual MDS for Resident 3 showed cognitive impairment and a need for substantial to maximum assistance with bed-to-chair transfers. The resident’s care plan documented a self-care deficit related to decreased mobility and required assistance of two staff for transfers. Despite this, on the day in question, a nurse aide transferred the resident alone from bed to wheelchair without checking the resident’s Kardex for current transfer status, believing the resident was a one-person assist. The aide reported that she did not know how to access the Kardex on the kiosk and never looked at Kardexes for her residents. Following this transfer, the resident complained of left leg pain during the transfer and later that day had a red, warm, and slightly swollen left knee, which was reported to the nurse. Subsequent physician assessments documented ongoing left knee swelling, erythema, warmth, and pain with weight-bearing as reported by staff, although the resident denied pain at one point. An X-ray revealed a nondisplaced patella fracture of unclear cause, as the resident reported no fall. The facility’s internal accident/injury report concluded that the resident had an acute left knee fracture and that neglect was substantiated. The Nursing Home Administrator and DON confirmed that the nurse aide failed to follow the resident’s care plan transfer interventions, which resulted in the injury.
Failure to Prevent Elopement Due to Inadequate Supervision and Non-Functioning Wander Guard
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision and interventions to prevent elopement for a resident identified as being at risk. Facility policies required that an elopement risk observation be completed by a licensed nurse upon admission, re-admission, or significant change in status, and that interventions such as a Wander Guard device be implemented as needed. For one resident with dementia and a history of wandering, the care plan and physician orders specified the use of a Wander Guard, with function and placement to be checked every shift. However, documentation and interviews revealed that the resident was able to leave the facility unsupervised, and the Wander Guard system did not alarm as intended. On the day of the incident, the resident accessed the elevator, exited the building, and was later returned by EMS. Staff failed to recognize the event as an elopement, did not notify administrative staff until the following day, and did not perform a physical assessment or notify the resident's family upon return. The Wander Guard device was found to have a low battery, and system reports confirmed that the device's battery status had been low on the day of the elopement. Despite this, staff had charted that the Wander Guard was functioning for all shifts, and no immediate action was taken to check or replace the device after the resident was returned. Interviews with nursing staff and the administrator confirmed that the alarm system was not functioning properly prior to the elopement and that staff did not follow policy in responding to the incident. The administrator acknowledged that the Wander Guard should have been checked and replaced after the resident's return, and that no new interventions were implemented until the following day. The failure to ensure the proper functioning of the Wander Guard system and to respond appropriately to the elopement placed the resident in immediate jeopardy.
Removal Plan
- Resident 3's wander guard transmitter was replaced with a new transmitter and checked for function.
- A facility wide sweep was conducted on all in house wander guard transmitters to ensure proper function and battery life.
- Any transmitters with a low battery life or improper function were replaced.
- Disciplinary action was enforced with the staff member who failed to respond to the incident in a timely and appropriate manner.
- All licensed nursing staff were re-educated on the elopement policy and procedure.
- All licensed nursing staff were also re-educated on the wander guard system function and documentation.
- All new staff and agency staff will receive the education.
- The Director of Nursing or designee added checking the transmitter battery life to the weekly audit tool and the weekly audit tool would include wander guard placement and battery status.
- Any transmitters with a low battery status would be replaced at the time of discovery.
- The wander guard system check was completed daily and will continue to be checked for function daily.
- System check audits would be completed by the Building Services Director or designee daily for three months and transmitter audits would be completed weekly for four months, and then monthly for three months.
- Upon admission, all residents would receive an elopement assessment and the assessments would determine interventions as needed.
- Updates would be added to the resident care plan and discussed with the interdisciplinary team.
- Audit results would be reported to the Quality Assurance Performance Improvement committee to identify trends, further opportunities for quality improvement, and needs for additional education/re-education.
Significant Medication Error Due to Pharmacy Labeling
Penalty
Summary
A medication error occurred when a resident, who was moderately cognitively impaired and required staff assistance for daily care, was administered the wrong medication for several days. The resident was supposed to receive rosuvastatin calcium, but due to a pharmacy labeling error, was instead given warfarin tablets. The error was discovered when a medication nurse identified a discrepancy in the medication card, which was labeled as rosuvastatin calcium but contained warfarin. The resident's clinical records showed that she had diagnoses including heart failure and was discharged from the facility after the incident. Following the administration of the incorrect medication, the resident's blood work revealed a critically elevated INR of 7.0, indicating a significant alteration in blood clotting time. The facility notified the physician and family, and the pharmacy was contacted regarding the labeling error. However, there was no documented evidence that the facility investigated whether other medication cards in the facility were also mislabeled by the pharmacy. The facility later ended its contract with the pharmacy due to this breach in service.
Failure to Implement Wound Consultant Recommendations for Pressure Ulcer Care
Penalty
Summary
A facility failed to follow pressure ulcer treatment recommendations for a resident who was cognitively impaired, required assistance for care needs, and had a diagnosis of atherosclerotic heart disease. Upon admission, the resident had an order to apply skin prep to the heels every shift. On July 17, a nurse documented a blood-filled blister on the resident's left heel, and a wound consult was ordered. The following day, the wound care consultant assessed the resident and recommended applying skin prep to the base of the wound and securing it with a bordered foam dressing. However, no new orders were obtained to reflect this recommendation. Review of the resident's treatment administration records showed that the bordered foam dressing was not applied to the left heel from July 18 through July 25, despite the consultant's recommendation. By July 25, the resident's left heel wound had progressed to a Stage 3 pressure ulcer. An interview with the Assistant Nursing Home Administrator confirmed that the wound care orders, including the foam dressing, were not added to the resident's wound orders, resulting in the recommended wound care not being completed.
Medication Administration Error Due to Pharmacy Packaging
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate receiving, dispensing, and administration of medication for a resident. According to facility policy, medications are to be administered as prescribed and in accordance with manufacturer specifications and good nursing practices. However, a medication card delivered from the pharmacy was labeled as rosuvastatin calcium but actually contained coumadin tablets. This error resulted in the resident, who was moderately cognitively impaired and had a diagnosis of heart failure, receiving coumadin instead of the prescribed rosuvastatin calcium for several days before the mistake was identified. Clinical documentation showed that the error was discovered when staff became aware that the medication card contained the wrong medication. The resident subsequently underwent lab work, which revealed an elevated INR, and the physician was notified. The incident was confirmed through interviews and review of records, which indicated that the pharmacy had packaged the medication incorrectly, leading to the administration error.
Failure to Follow Care Plan for ADL Assistance Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan for assistance with activities of daily living (ADLs) and fall prevention. The resident, who had a diagnosis of morbid obesity and was identified as being at risk for falls due to balance issues, required assistance from two staff members for bed mobility and transfers, as documented in the care plan. Despite this, a nurse aide provided in-bed care with only one staff member present. During the provision of care, the resident was rolled onto his left side to be changed after a bowel movement. While the nurse aide was cleaning the resident, he reached for an item on his nightstand and rolled out of bed, falling onto the floor and landing on his right hip. The resident reported hip pain, and subsequent assessment and x-ray revealed an intertrochanteric fracture of the right hip. The incident was confirmed by statements from both the nurse aide and the resident, as well as documentation in the clinical record. The facility's investigation determined that neglect had occurred because the nurse aide did not adhere to the care plan, which required two staff for bed mobility. The nurse aide had previously completed training on preventing, recognizing, and reporting abuse, but failed to follow the established protocol for this resident, resulting in the fall and injury.
Failure to Follow Care Plan for Fall-Risk Resident Results in Injury
Penalty
Summary
A deficiency occurred when staff failed to implement care-planned interventions for a resident identified as a fall risk. The resident had a history of morbid obesity, decreased mobility, and required assistance from two staff members for bed mobility and transfers, as documented in the care plan. Despite these documented needs, an agency nurse aide provided in-bed care with only one assist, contrary to the care plan requirements. During routine care, the nurse aide rolled the resident onto his left side to change him after a bowel movement. While being assisted, the resident reached for an item on his nightstand and rolled out of bed, falling onto the floor and landing on his right hip. The resident reported hip pain and was found to have small scratches on his right elbow. Subsequent x-rays revealed an intertrochanteric fracture of the right hip, which was determined to be likely acute in nature. The investigation confirmed that the nurse aide did not follow the resident's care plan, which specified the need for two-person assistance with bed mobility. The aide admitted to providing care alone and was unaware of the specific requirements at the time. This failure to follow the care plan directly resulted in the resident's fall and subsequent injury.
Failure to Follow Care Plan for Bed Mobility Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident, who had a history of morbid obesity, decreased mobility, and was care planned to require assistance from two staff members for bed mobility and transfers, experienced a fall resulting in a right hip fracture. The resident's care plan specifically indicated the need for two-person assistance due to self-care deficits and balance issues. Despite these documented needs, a nurse aide provided in-bed care with only one assist during a routine care activity. During the incident, the nurse aide rolled the resident onto his left side to perform hygiene care after a bowel movement. While the resident was being repositioned, he reached for an item on his nightstand and rolled out of bed, landing on his right hip. The resident reported pain, and subsequent assessment and x-ray revealed an intertrochanteric fracture of the right hip. The nurse aide later acknowledged that she did not follow the care plan and believed she could manage the task alone. Investigation confirmed that the nurse aide failed to adhere to the resident's care plan, which required two staff for bed mobility. This failure to follow the established care plan and provide adequate supervision directly resulted in the resident's fall and injury. The deficiency was cited as past non-compliance after review of clinical records, staff statements, and investigation documents.
Failure to Follow Physician's Orders for Medication and Weight Monitoring
Penalty
Summary
The facility failed to ensure that residents received care and treatment in accordance with professional standards of practice. For Resident 15, who was cognitively impaired and diagnosed with hypertension, the facility did not adhere to the physician's orders regarding the administration of Labetalol. Despite the order to withhold the medication if the resident's heart rate was below 50 beats per minute, the medication was administered on two occasions when the heart rate was 44 bpm and 47 bpm, respectively. Additionally, the facility did not follow physician's orders for Residents 70 and 95 regarding weight monitoring and physician notification. Resident 70 experienced a 4.4-pound weight gain overnight, but there was no documented evidence that the physician was informed. Similarly, Resident 95 had a significant weight gain of 47.8 pounds over a few days, yet the physician was not notified. These failures were confirmed through staff interviews, indicating a lack of adherence to prescribed care protocols.
Plan Of Correction
Resident 15 had no adverse reactions to having an antihypertensive medication (a medication that treats hypertension) administered outside of heart rate parameters set forth by the physician. The physician was made aware of the medication administration outside of the parameters. Resident 70 had no adverse reactions to not having the medical doctor (MD) notified of a weight gain in one day. The resident is no longer in the facility. Resident 95 had no adverse reactions to not having the MD notified of a weight gain in one day. The resident is no longer in the facility. Facility-wide sweep for all residents who have heart rate parameters with antihypertensive medications to ensure that heart rate parameters were followed according to physician order was conducted. Facility-wide sweep for all residents with significant weight loss was conducted to ensure proper physician notification. Any issues identified were corrected at time of discovery. All licensed nursing staff was re-educated on heart rate parameters surrounding antihypertensive medications and notification of physician in addition to significant weight change education. The Assistant Nursing Home Administrator or designee will conduct audits to ensure that heart rate parameters with antihypertensive medications are followed and that all significant weight changes have physician notification, weekly for 4 weeks and then monthly for 2 months. Identified issues will be addressed at time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education.
Failure to Maintain Accountability of Controlled Medications
Penalty
Summary
The facility failed to ensure the accountability of controlled medications for three residents. For one resident, the records showed that a Fentanyl patch was applied on multiple dates, but there was no documented evidence that the old patches were destroyed as required. This lack of documentation was confirmed by the Nursing Home Administrator during an interview. Another resident had orders for Oxycodone/Tylenol to be administered as needed, but the medication administration record did not show evidence of administration on several dates when the controlled drug record indicated it was signed out. Similarly, a third resident had orders for Percocet, but the medication administration record did not reflect administration on dates when the controlled drug record showed it was signed out. The Nursing Home Administrator confirmed the absence of documentation for the administration of these medications. These findings indicate a failure in maintaining accurate records and accountability for controlled substances, as required by the regulations.
Plan Of Correction
Residents 28 and 36 were noted to not have any adverse effects from not having documented medication administration in the electronic medical record (EMR). Resident 4 was noted to not have any adverse effects from not having documentation of destroyed controlled substances. A facility-wide sweep of all residents in-house with the physician order of Percocet was conducted to ensure all administrations were documented in the narcotic book and matched the EMR. A facility-wide sweep of all residents with Fentanyl patches had documentation of medication destruction upon removal on the narcotic (NARC) signoff sheet. All licensed nurses were educated on medication administration and documentation in the EMR, as well as the destruction of controlled substances. The Director of Nursing or designee will conduct audits to ensure that all Percocet administrations are documented in the narcotic book and match the EMR, and that Fentanyl patches have documentation of medication destruction upon removal on the NARC sheet weekly for 4 weeks and monthly for 2 months. Identified issues are addressed at the time of discovery. Audit results are reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education/re-education.
Sanitary Conditions Not Maintained in Food Service
Penalty
Summary
The facility failed to ensure that food was prepared and served under sanitary conditions, as required by professional standards for food service safety. During an observation in the main kitchen, several food items, including American cheese, scones, Danish pastries, apple pie, blueberry pie, and a bag of brownie mix, were found open to air and undated. This was confirmed by an interview with the Executive Chef, who acknowledged that these items should have been covered and dated according to the facility's policy on food and nutrition services. Additionally, an observation in the kitchenette revealed that a Nurse Aide entered the area without wearing a hairnet, which is a violation of the facility's policy requiring employees to wear appropriate hair restraints. This was confirmed in an interview with the Nursing Home Administrator, who acknowledged that the Nurse Aide should have been wearing a hairnet while in the food preparation area. These findings indicate a failure to adhere to the facility's established protocols for maintaining sanitary conditions in food service areas.
Plan Of Correction
All food products identified as open to air and undated were immediately discarded. This includes one-quarter pound of American cheese, 15 scones, 6 Danishes, 1 apple pie, 1 blueberry container, and 1 brownie mix. Nurse Aide 3 has since been removed from duties and dismissed from Redstone. A facility-wide sweep of all food storage areas and pantries was conducted to ensure proper storage. All issues identified were corrected at the time of discovery. The System Food Service Director and dietary staff were re-educated on the proper storage of food products. The System Food Service Director, dietary and nursing staff was re-educated on proper food handling and PPE etiquette. The System Food Service Director or designee will conduct audits to ensure proper storage of all food products, weekly X4 weeks, monthly x2 months. The Director of Nursing Assistants (DNA) or designee will conduct spot-check compliance audits to ensure proper food handling and personal protective equipment (PPE) etiquette during meals weekly X4 weeks, monthly X2 months. Identified Issues are addressed at the time of discovery. Audit results are reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education/re-education.
Failure to Document Hospice Wound Assessments
Penalty
Summary
The facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for a resident who received hospice services. The agreement between the facility and the hospice provider, dated March 5, 2021, stipulated that hospice services should be provided at the same level as if the resident were in their own home. The facility's policy, dated September 27, 2024, required the hospice provider to document pertinent information relative to each visit throughout the course of care. The resident in question had a Stage 3 pressure ulcer and was receiving hospice care. The care plan required staff to document weekly the treatment and measurements of the wound. However, there was no documented evidence of the weekly wound assessments and measurements being completed for several weeks, specifically from September 8 through November 22, 2024. This lack of documentation indicated a failure to meet the requirements set forth in the hospice agreement and facility policy. An interview with the Director of Nursing confirmed that the hospice was responsible for following the resident's wounds during their visits. However, the hospice did not provide any documented evidence of their weekly wound assessments and measurements being completed on the specified dates. This oversight led to the deficiency cited in the report.
Plan Of Correction
A communication was made to the hospice team to ensure all documentation was made available in resident 35's electronic medical record (EMR) as it relates to weekly wound assessment/measurements for the weeks of September 8 through 14, 2024; September 15 through 21, 2024; September 22 through 28, 2024; September 29 through October 5, 2024; October 6 through 12, 2024; October 13 through 19, 2024; and November 17 through 22, 2024. A sweep of all hospice caseloads was conducted to ensure all wound records of hospice services were rendered into the patient's EMR. Any issues identified were corrected at the time of discovery. The skilled nursing interdisciplinary team (IDT) and hospice IDT members were re-educated on having all records of hospice services rendered to the patient available in the patient's electronic medical record. The risk management assistant or designee will conduct audits to ensure all wound documentation of hospice services rendered is made available in the hospice patient's electronic medical record weekly X4 weeks, monthly X2 months. Identified issues will be addressed at the time of discovery. Audit results are reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education/re-education.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident, leading to a deficiency in compliance with regulatory requirements. The resident, who was cognitively intact and required assistance for daily care, suffered an ankle fracture. Despite the facility's policy mandating a thorough investigation for injuries of unknown origin, there was no documented evidence that such an investigation was conducted to rule out abuse or neglect as potential causes. The Director of Nursing interviewed the resident, who denied any abuse, and concluded the investigation without further action. However, there was no documentation to show that neglect was considered or ruled out as a cause for the fracture. This lack of a comprehensive investigation into the resident's injury of unknown origin resulted in a failure to meet the regulatory requirements for investigating and preventing potential abuse or neglect.
Plan Of Correction
I hereby acknowledged the CMS 2567-A, issued to Redstone Highlands Health Care Center for the survey ending March 20, 2025 and attest that all deficiencies listed on the form will be corrected in a timely manner. This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Redstone Highlands Healthcare Center agrees with the allegations and citations listed on the statement of deficiencies. Redstone Highlands Healthcare Center maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Redstone Highlands Healthcare Center's written credible allegation of compliance. By submitting this plan of correction, Redstone Highlands Healthcare Center does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Redstone Highlands Healthcare Center reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding. Resident 24 was assessed and noted to have no adverse effects related to the investigation of ruled-out neglect from the incident dated October 12, 2024. The resident is followed to ensure psycho-social needs are met. No new orders from the physician. The resident has had no adverse effects from the completed investigation of injury of unknown origin. A facility-wide sweep of all residents with pain scales presenting with unidentified pain source, if applicable. Any issues identified were corrected at the time of discovery, and an investigation will be initiated to rule out abuse/neglect and identify the cause, if applicable. The whole house staff was educated on the Abuse / Neglect Prohibition policy and procedure. The Director of nursing (DON) or designee will conduct audits to ensure all pain scales with unidentified sources are investigated to rule out abuse/ neglect to completion and documented weekly for 4 weeks, then monthly for 2 months. Identified issues will be addressed at the time of discovery. Audit results are reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education/re-education.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in the documentation of their medical status. For one resident, the MDS assessment did not accurately reflect the administration of anticoagulant and diuretic medications, despite physician's orders and medication administration records indicating that these medications were given during the seven-day look-back period. This discrepancy was confirmed through an interview with the Registered Nurse Assessment Coordinator (RNAC). Additionally, the facility inaccurately coded the discharge status for two residents. One resident was discharged home with home health services, but the MDS assessment incorrectly indicated a discharge to a short-term general hospital. Another resident's death tracking MDS assessment inaccurately recorded the resident as deceased, while nursing notes confirmed the resident was sent to a hospital for further evaluation and treatment. These inaccuracies were confirmed through interviews with the Assistant Campus Director.
Plan Of Correction
Residents 69 and 96 have discharged from the facility. Resident 55 MDS was updated with appropriate coding. A facility-wide sweep of all residents meeting the requirements of anticoagulants and diuretic medications on admission assessments, discharge status in Section A2105 of discharge assessments, and accurate discharge to the hospital minimum data set (MDS) tracking's were opened were completed going back to February 1, 2025. Any issues identified were corrected at the time of discovery. The Registered Nurse Assessment Coordinators (RNAC) was re-educated regarding the resident assessment instrument (RAI) Manual for Section N: Medications and Section A: Identification Information. The Nursing home administrator (NHA) or designee will conduct audits to ensure that Admission MDS assessments with anticoagulant and diuretics coded were completed correctly per the RAI Manual, and discharge assessments will have accurate discharge tracks and locations completed correctly per the RAI Manual required schedule weekly X4 weeks, then monthly X2 months. Identified issues will be addressed at time of discovery. Audit results are reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education/re-education.
Failure to Develop Baseline Care Plans for Residents
Penalty
Summary
The facility failed to ensure that baseline care plans were developed for three residents, which included necessary information regarding their immediate care needs. The facility's policy required that a baseline care plan be initiated upon admission and completed within 48 hours, individualized to each resident. However, for Resident 89, who required a feeding tube for nutritional support, there was no documented evidence of a baseline care plan addressing the need for Enhanced Barrier Precautions (EBP) due to the feeding tube. Similarly, Resident 94, who had a Foley catheter for urinary retention, also lacked a baseline care plan addressing EBP needs. Additionally, Resident 95, who had a Foley catheter and was on anticoagulant and diuretic medications, did not have a baseline care plan that included EBP needs. Interviews with the Nursing Home Administrator and the Assistant Campus Director confirmed the absence of these baseline care plans for the residents' specific care and treatment needs. The facility's failure to develop these plans was identified during a review of facility policies, clinical records, and staff interviews.
Plan Of Correction
Resident 89, 94 and 95 had no adverse reactions related to not having a baseline care plan demonstrating the need for enhanced barrier precautions (EBP), anticoagulants or diuretics. Resident 89 is no longer in the facility. Resident 94 is no longer in the facility. Resident 95 is no longer in the facility. A facility-wide sweep of all foley catheters, feeding tubes, anticoagulants and diuretics was conducted to ensure that a baseline care plan was initiated with the related items in place. Any issues identified were corrected at time of discovery. The registered assessment coordinator (RNAC) and all licensed nursing staff were re-educated regarding updating the baseline care plan with enhanced barrier precautions (EBP) for foley catheters and feeding tubes as well as to demonstrate the use of anticoagulants and diuretics. The Assistant Nursing Home Administrator or designee will conduct audits to ensure that the baseline care plan is initiated and the proper related items are in place, weekly X4 weeks, and then monthly X2 months. Identified issues will be addressed at time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, which led to deficiencies in addressing their specific care needs. For one resident, who was cognitively impaired and required assistance for daily care needs, there was no documented care plan to address the management of her colostomy. This oversight was confirmed by the Nursing Home Administrator during an interview, acknowledging that a care plan should have been in place for the resident's colostomy care. Another resident, who was cognitively intact and had a diagnosis of diabetes, did not have a care plan developed to address her diabetes management or the use of a continuous glucose monitoring system. Despite having physician orders for the use of a Freestyle Libre 3 sensor, there was no documentation of a care plan to support her treatment needs. This lack of documentation was also confirmed by the Nursing Home Administrator, indicating a failure to provide individualized care planning for the resident's diabetes management.
Plan Of Correction
Resident 40's care plan was updated to include the presence of an ostomy and interventions to address the care and maintenance. Resident 55's care plan was updated to include Diabetes Mellitus and the use of a continuous glucose monitor. Facility-wide sweep was conducted to capture other residents who have colostomies and diabetes and their care plans to ensure that colostomy status, diabetes mellitus and continuous glucose monitoring have been included with interventions in the care plans. Any issues identified were corrected at time of discovery. The registered nurse assessment coordinator (RNAC) and licensed nursing staff were re-educated on the need to update the comprehensive care plan accurately and timely when resident changes occur. The Assistant Nursing Home Administrator or designee will conduct audits to ensure that the care plan updates are completed timely weekly X4 weeks, then monthly fX2 months. Identified issues will be addressed at time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education.
Failure to Update Resident Care Plan Post-Antibiotic Therapy
Penalty
Summary
The facility failed to update and revise a resident's care plan to reflect specific care needs, as required by regulations. The deficiency was identified for one resident, who was cognitively intact and required assistance for daily care needs. The resident had been diagnosed with pneumonia and was on antibiotic therapy. The care plan, dated March 4, 2025, indicated that staff were to administer the antibiotic medication as ordered by the physician. However, the care plan was not updated when the resident's antibiotic therapy was completed. This oversight was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the care plan should have been updated. The facility's policy, dated September 27, 2025, stated that care plans should be individualized and updated by the licensed nurse and interdisciplinary team as needed with changes as applicable.
Plan Of Correction
Resident 73's care plan has been updated to demonstrate discontinued orders and interventions appropriate to identified needs. A facility-wide sweep of all discontinued antibiotic therapy was conducted. Any issues identified were corrected at the time of discovery. The registered nurse assessment coordinator (RNACs) and licensed nursing staff were re-educated regarding timely resident care plan revisions when resident changes occur. The Assistant Nursing Home Administrator or designee will conduct audits to ensure that care plan revisions are completed timely, weekly for 4 weeks, then monthly for 2 months. Identified issues will be addressed at the time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education.
Failure to Clarify Provider's Orders for Wound Care
Penalty
Summary
The facility failed to clarify a provider's orders for a resident, leading to a deficiency in meeting professional standards of quality care. The resident, who was cognitively intact and required assistance for daily care needs, had a history of a left hip fracture, diabetes, and dementia. The resident's care plan included orders for wound care on the heels due to deep tissue injury and pressure ulcers. However, discrepancies were found between the verbal orders given by the wound consultant and the written orders documented in the clinical records. The verbal orders instructed the wound nurse to change the dressings every other day, while the written assessments indicated daily changes. The inconsistency in the orders was further complicated by the wound consultant's process, where verbal orders were given to the wound nurse, but the consultant's assistant typed the assessments, leading to mismatched documentation. This lack of clarity and consistency in the orders resulted in the facility's failure to meet the professional standards of quality care as required by the Pennsylvania Nursing Practice Act and the comprehensive care plan regulations.
Plan Of Correction
Resident 48 had no adverse reactions to having wound care orders not matching the wound physician's orders from rounding notes. Physician's order has been updated and the electronic medical record (EMR) reflects update. Resident 48 has since been discharged from the facility. A facility-wide sweep on all in-house residents with active wound care orders was conducted to ensure all rounding wound care physician orders were correctly transcribed into the EMR. Any issues identified were corrected at time of discovery. The wound care coordinator and all licensed nursing staff was re-educated on transcription of wound care orders from the rounding wound physician into the EMR. The Assistant Nursing Home Administrator or designee will conduct audits to ensure that EMR orders for wound care match the MD rounding report from the rounding wound physician, weekly X4 weeks then monthly X2 months. Identified issues will be addressed at time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure the secure storage of medications, as evidenced by an unlocked and unsecured medication cart on the first floor, which was accessible to residents, family, and staff. This was observed while a registered nurse was attending to a resident in a room. Additionally, loose pills were found in the second drawer of the medication cart, not in their original pharmacy packaging, which was confirmed by an LPN to be inappropriate. Furthermore, the facility did not store unopened and unused multi-dose containers of insulin according to the manufacturer's instructions. An unopened Insulin Aspart Pen Injector for a resident was found in the medication cart instead of being refrigerated as required. The facility also failed to store refrigerated controlled medications in a separately locked, permanently affixed container. A red plastic box containing Ativan Intensol was not permanently affixed to the refrigerator, allowing it to be removed, which was confirmed by the Assistant Director of Nursing.
Plan Of Correction
All medication carts were rounded on and ensured to be locked. Any loose medication within the drawer of the medication cart was destroyed by nursing staff via drug buster. The insulin pen within the medication cart was immediately discarded. Controlled substance contents was moved to a permanently affixed box within the refrigerator that was preexisting. A Facility-wide sweep was conducted to include: all medication carts to ensure that they are locked when not in use; that there are no loose medications in the drawers; and that all insulin is dated once removed from the refrigerator. In addition, a facility-wide sweep of medication room refrigerators was conducted to ensure that all controlled substance boxes are permanently affixed to the refrigerator. Any issues identified were corrected at time of discovery. All licensed nursing staff was re-educated on the policies including but not limited to medication storage, disposition and labeling. The director of nursing (DON) or designee will conduct audits to ensure that all med carts are locked when not in use, no loose medications are left in the med cart, all insulin pens are dated when outside of the refrigerator and all controlled substance boxes in the medication room refrigerators are permanently affixed, weekly X4 weeks then monthly X2 months. Identified issues will be addressed at time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during the administration of treatment for a resident with pressure ulcers. The resident, who was cognitively intact and required assistance for daily care needs, had a diagnosis that included a left hip fracture, diabetes, and dementia. Physician's orders indicated that the resident's bilateral heels were to be cleansed and dressed every other day due to pressure ulcers. During an observation, a registered nurse provided wound care to the resident's heels without wearing a gown, which was against the facility's policy for enhanced barrier precautions (EBP). The nurse removed the soiled dressing from the resident's left foot, removed her gloves, and donned clean gloves without performing hand hygiene in between. This was confirmed by the nurse during an interview, acknowledging the lapse in hand hygiene. Further interviews revealed that the resident should have been on EBP due to having wounds, but there were no EBP supplies available in the resident's room. The Nursing Home Administrator confirmed that EBP was not in place for the resident and that the nurse should have washed her hands after glove removal and worn a gown during the treatment administration.
Plan Of Correction
Resident 48 had no adverse reactions from Registered Nurse 1's providing wound care without wearing a gown per enhanced barrier precautions (EBP) protocol. Resident 48 has since been discharged in good condition from the facility. Registered Nurse 1 was immediately re-educated on EBP precautions and proper hand hygiene. A facility-wide sweep was conducted of all in-house residents with wounds requiring EBP to ensure EBP is followed during wound/skin treatments. Any issues identified were corrected at the time of discovery. All licensed therapists and nursing staff were re-educated on EBP protocol and proper hand hygiene. The Infection Control Preventionist or Designee will conduct spot-check audits to ensure EBP protocol is being followed along with proper hand hygiene during wound/skin treatments for weekly X4 weeks and monthly X2 months. Identified issues will be addressed at the time of discovery. Audit results are reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education/re-education.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their responsible parties regarding the reasons for hospital transfers, as required by regulations. This deficiency was identified for five residents during a review of clinical records and staff interviews. The facility did not document the reasons for the transfers in writing, nor did they notify the residents' responsible parties, which is a violation of the notice requirements before transfer or discharge. Resident 28, who was cognitively intact and dependent on staff for daily care, was transferred to the hospital without written notification to the responsible party. Similarly, Resident 39 was admitted to the hospital with a urinary tract infection, and there was no documented evidence of written notice provided. Resident 40, who was cognitively impaired and required maximum assistance, was sent to the hospital following a fall, but again, no written notice was given to the responsible party. Resident 48, who had multiple diagnoses including a hip fracture and dementia, was transferred to the hospital twice due to worsening kidney function, yet no written notice was provided. Lastly, Resident 69, who had cancer and other conditions, was sent to the hospital due to ostomy issues, but there was no documented evidence of written notification to the resident or their responsible party. Interviews with facility administrators confirmed the lack of written notices for these transfers.
Plan Of Correction
Residents 69 and 48 have since been discharged from the facility. Residents 39, 28, and 40 have not been sent out of the facility since findings. A sweep of all resident transfers was conducted to ensure there was documentation evidence of written notice to the resident's responsible party regarding the reasoning for the transfer from the facility. All issues discovered were corrected at the time of discovery. The navigation team was re-educated on written notice to the resident's responsible party when a transfer is facility-initiated. The Nursing home administrator (NHA) or designee will conduct audits to ensure all facility-initiated transfers have documented written notice to the responsible party regarding the reason for transfer weekly X4 weeks, then monthly X2 month. Identified issues will be addressed at the time of discovery. Audit results are reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education/re-education.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to serve food items at palatable temperatures, as evidenced by resident interviews, observations, and staff interviews. The facility's policy required cold food to be served between 33 and 50 degrees Fahrenheit and hot food between 135 and 155 degrees Fahrenheit. However, residents reported that food served in their rooms was often cold, and a food committee meeting confirmed inconsistent food temperatures. During an observation of lunch meal service, a test tray revealed that iced tea was 49 degrees F, coffee was 138 degrees F, mixed vegetables were 119 degrees F, pork was 129 degrees F, and rice was 136.2 degrees F. The Dietary Director confirmed that the food was not at an appetizing temperature.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to ensure timely notification of a resident's physician regarding a change in condition. Resident 40, who was cognitively impaired and at risk for dehydration due to diuretic use, had physician's orders for daily weights with instructions to notify the physician if there was a significant weight change. The resident refused daily weights, and although a communication form was sent to the physician, there was no documented response as of two days later. The Director of Nursing confirmed the lack of documented evidence of physician notification about the refusals, which should have been done according to the facility's policies.
Failure to Maintain Comfortable Air Temperatures in Dining/Activity Room
Penalty
Summary
The facility failed to provide comfortable air temperatures in the second-floor dining/activity room. Observations revealed that residents were eating lunch with blankets and long sleeves on, and they verbalized that the room was cold. Interviews with a group of residents confirmed that the second-floor dining room was very cold, making them uncomfortable during activities and meals. An Activities Aide noted that the room thermometer was set at 70 degrees Fahrenheit, but residents still found the room too cold, affecting their participation in activities and meals. The Maintenance Director confirmed that the air conditioner was turned on throughout the facility, and the heat was turned off, making it impossible to run both simultaneously. He acknowledged residents' complaints about the cold and mentioned using portable heaters during the winter. Observations and interviews confirmed that the room temperature was 67 degrees Fahrenheit, and the room had many unsealed windows letting in cold air. The Director of Nursing confirmed that the room should be at a comfortable temperature for the residents.
Failure to Complete Annual MDS Assessments on Time
Penalty
Summary
The facility failed to ensure that a comprehensive annual Minimum Data Set (MDS) assessment was completed within the required time frame for two residents. According to the Resident Assessment Instrument (RAI) User's Manual, an annual MDS assessment must be completed no later than 366 days after the previous comprehensive assessment's Assessment Reference Date (ARD) and within 92 days since the ARD of the previous quarterly assessment. For Resident 11, the ARD of the next annual MDS was 35 days late, and for Resident 52, it was 25 days late. The Director of Nursing confirmed that the annual MDS assessments for these residents were completed late during an interview on April 25, 2024.
Failure to Develop Care Plan for Exit-Seeking Behavior
Penalty
Summary
The facility failed to develop an individualized care plan for a resident exhibiting exit-seeking behavior. A quarterly Minimum Data Set (MDS) assessment for the resident revealed cognitive impairment and behaviors such as hitting, kicking, yelling, screaming, and rummaging. A nursing note documented an incident where the resident attempted to leave a locked unit and was brought back by a nurse aide after a visitor mistakenly let her out. Despite this incident, there was no documented evidence of a care plan addressing the resident's exit-seeking behavior. The Director of Nursing confirmed that a care plan should have been developed but was not.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that a resident's care plan was updated to reflect the resident's specific care needs for two residents. For Resident 8, the admission Minimum Data Set (MDS) assessment dated February 8, 2024, indicated cognitive impairment and extensive assistance with daily care needs. However, the care plan dated February 5, 2023, included the use of heparin and antibiotics, which the resident was not receiving as of April 22, 2024. The Director of Nursing confirmed on April 24, 2024, that the care plan was not updated to reflect the current medication orders for Resident 8. For Resident 20, the quarterly MDS assessment dated March 12, 2024, revealed severe cognitive impairment and extensive assistance with daily care needs. The care plan revised on March 5, 2024, indicated the use of a Wanderguard and identified the resident as an elopement risk. Despite a nursing note from October 2, 2023, documenting an elopement incident, the care plan was not updated to include new interventions to prevent further elopements. The Director of Nursing confirmed on April 25, 2024, that the care plan should have been updated to reflect these new interventions.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter. The facility's policy required catheter care to be performed at least twice daily and after bowel incontinence or when secretions accumulated around the urinary meatus. The care plan for the resident indicated that catheter care should be provided every shift. However, documentation revealed that catheter care was not completed during several evening and night shifts in March and April 2024. This was confirmed by the Assistant Director of Nursing.
Failure to Ensure Timely Re-Weighs and Notifications for Significant Weight Loss
Penalty
Summary
The facility failed to ensure timely re-weighs, physician notification, and intervention for a resident who experienced significant weight loss. According to the facility's weight management policy, a resident's weight should be retaken if there is a change of five percent or more since the last assessment, and if there is an actual five percent or more gain or loss in one month, the resident's family, physician, and the nutrition services director should be notified. Resident 320, who was cognitively intact and required extensive assistance for daily care needs, experienced a 10.4-pound weight loss in five days and a further drop in weight over the following week. Despite these significant changes, there was no documented evidence that the resident was re-weighed or that the necessary notifications were made according to the facility's policy. A dietary note indicated that the dietary department was aware of the resident's significant weight loss and had recommended supplements to address the issue. However, the resident continued to lose weight, and there was no documentation of re-weighs or notifications to the family, physician, or nutrition services director. The Director of Nursing confirmed that the weight loss was not noted until five days after it first occurred, indicating a failure to follow the facility's policy on weight management and timely intervention.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to ensure the physician's order for oxygen was followed for one resident. The facility policy for oxygen administration indicated that oxygen should be started at the prescribed liter flow and may be titrated according to physician orders. Resident 10, who was cognitively intact and required assistance for daily care needs, had diagnoses of pulmonary fibrosis and pneumonia. The physician's orders and care plan for Resident 10 specified an oxygen flow rate of 0-6 liters. However, observations revealed that the resident was using oxygen at a flow rate of 7 liters. Interviews with a Licensed Practical Nurse and the Director of Nursing confirmed that the oxygen flow rate was set incorrectly and should have been within the prescribed range.
QAPI Committee Ineffectiveness in Addressing Recurring Deficiencies
Penalty
Summary
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. The current survey identified repeated deficiencies related to the development and implementation of comprehensive care plans, care plan timing and revision, and respiratory care. These deficiencies were previously cited in a survey ending May 24, 2023, and the facility had developed plans of correction that included monitoring by the QAPI committee. However, the QAPI committee was ineffective in maintaining compliance with these regulations, as evidenced by the repeated deficiencies found in the current survey ending April 25, 2024. Specifically, the facility's plan of correction for the deficiency regarding the development and implementation of comprehensive care plans, cited under F656, was not effective. Similarly, the plan of correction for care plan timing and revision, cited under F657, and the plan for respiratory care, cited under F695, were also ineffective. The QAPI committee's failure to maintain compliance with these regulations indicates that the quality assurance systems in place were not sufficient to address and correct the recurring deficiencies.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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