Inspection visit
Health inspection
15 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 15 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
Based 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 seven of 41 residents reviewed (Residents 15, 21, 22, 44, 63, 66, 75).
Residents Affected - Few
Findings include:
The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides
guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated
assessments of a resident's abilities and care needs), dated October 2019, revealed that the nurse was
expected to listen to the resident, ask primary caregivers about the resident's speech, review the medical
record, and determine the quality of the resident's speech. Section B0600 (Speech Clarity) was to be coded
with a zero (0) for clear speech, a one (1) for unclear speech, and a two (2) for no speech. Section B0700
(Makes Self Understood) was to be coded zero (0) if the resident was understood, one (1) if the resident
was usually understood, two (2) if the resident was sometimes understood, and three (3) if the resident was
rarely/never understood. The section was not to be coded as rarely/never understood if the resident
completed any of the resident interviews, as the interviews were conducted during the look-back period and
should be factored in when determining the residents' ability to make himself/herself understood during the
entire 7-day look-back period. Section B0800 (Ability to Understand Others) was to be coded zero (0) if the
resident understands others, one (1) if the resident usually understands others, two (2) if the resident
sometimes understands others, and three (3) if the resident rarely/never understands others. Section
C0100 (Should a Brief Interview for Mental Status Be Conducted) was to be coded zero (0) No if the
resident was rarely/never understood or one (1) Yes if the resident could participate in the interview. Section
J0200 (Should Pain Assessment Interview Be Conducted) was to be coded zero (0) No if the resident was
rarely/never understood and one (1) Yes if the resident interview should be attempted. Section D0100
(Should Resident Mood Interview be Conducted) was to be coded (0) No (resident is rarely/never
understood) or (1) Yes (continue with interview).
A quarterly Minimum Data Set (MDS) assessment (mandated assessments of a resident's abilities and
care needs) for Resident 15, dated April 1, 2023, revealed that Section B0700 (Makes Self Understood)
was coded with (2), indicating that the resident was sometimes able to be understood by others and
Section B0800 (Ability to Understand Others) was coded two (2), indicating that she sometimes
understood. However, Section C0100 was coded with a dash (-), indicating that the mental status interview
was not attempted/assessed and Section D (Mood) was coded with a dash (-), indicating that the mood
interview was not attempted/assessed.
A quarterly MDS assessment for Resident 21, dated March 11, 2023, revealed that Section B0700 (Makes
Self Understood) was coded with (2), indicating that the resident was sometimes able to be
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 24
Event ID:
396021
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redstone Highlands Health Care
6 Garden Center Drive
Greensburg, PA 15601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
understood by others and Section B0800 (Ability to Understand Others) was coded two (2), indicating that
she sometimes understood. However, Section C0100 was coded with a dash (-), indicating that the mental
status interview was not attempted/assessed and Section D (Mood) was coded with a dash (-), indicating
that the mood interview was not attempted/assessed.
An interview with the Clinical Consultant on May 24, 2023 at 2:29 p.m. revealed that Residents 15 and 21's
MDS were coded incorrectly and that sections C and D should have been completed.
The RAI User's Manual, dated October 2019, indicated that the intent of Section N0410G was to be coded
with the number of days the resident received a diuretic pill (a medication used to help the body get rid of
extra fluid and salt).
Physician's orders for Resident 22, dated April 27, 2021, included an order for the resident to receive
hydrochlorothiazide (a diuretic) every day for edema (swelling). The resident's Medication Administration
Record (MAR) for March 2023 revealed that the resident received hydrochlorothiazide every day during the
seven-day look-back period. However, a quarterly MDS assessment for Resident 22, dated March 16, 2023,
revealed that Section N0410G was coded zero (0), indicating that the resident did not receive a diuretic
during the last seven days.
An interview with the Clinical Consultant on May 24, 2023 at 2:29 p.m. confirmed that Resident 22's MDS
was coded incorrectly and should have reflected that the resident was receiving a diuretic.
The RAI User's Manual, dated October 2019, indicated that the intent of Section H0100 (Appliances) was
to be coded with the number of days the resident used an appliance related to their toileting, such as an
indwelling catheter, external catheter, ostomy, or intermittent catheterization (inserting a tube directly into
the bladder to drain urine).
Physician's orders for Resident 44, dated December 6, 2022, included an order for the resident to perform
a straight catheterization (cath) on himself every shift for urinary retention. The Resident's MAR, dated April
2023, indicated that the resident straight cathed himself at least once a shift during the seven-day look-back
period. However, a quarterly MDS assessment for Resident 44, dated April 20, 2023, revealed that Section
H0100D (intermittent catheterization) was coded (0), indicating that the resident did not straight cath
himself at least once a day during the last seven days.
An interview with the Clinical Consultant on May 24, 2023 at 2:29 p.m. confirmed that Resident 44's MDS
was coded incorrectly and should have reflected that he was straight cathed at least once daily during the
seven-day look-back period and did not.
The RAI User's Manual, dated October 2019, revealed that Section M0300G1 was to be coded with the
number of unstageable pressure injuries related to a deep tissue injuries (area of purple or maroon
discolored intact skin due to damage of underlying soft tissue). If Section M0300G1 was coded with a
number, then the number of these unstageable injuries present upon admission/reentry was to be coded in
section M0300G2.
A quarterly MDS assessment for Resident 63, dated May 5, 2023, revealed that Section M0300G1 was
marked 1 to indicate that the resident had one unstageable pressure ulcer related to a deep tissue injury.
Section M0300G2 was marked 0 to indicate that the deep tissue injury was not present upon
admission/readmission. However, a nursing note dated April 2, 2023, revealed that the resident returned to
the facility via emergency medical sercives (EMS). The resident was noted to have a deep tissue
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396021
If continuation sheet
Page 2 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redstone Highlands Health Care
6 Garden Center Drive
Greensburg, PA 15601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
injury to her right heel measuring 2.5 centimeters (cm) by 2 cm.
Level of Harm - Minimal harm
or potential for actual harm
Interview with the Director of Nursing on May 23, 2023, at 1:30 p.m. confirmed that Section M0300G2 of
Resident 63's quarterly MDS assessment, dated May 5, 2023, was coded incorrectly.
Residents Affected - Few
The RAI user's manual, dated October, 2019, revealed that Section A2100 was to be coded one (1) through
(8) depending on the location of the resident's discharge. If the resident was discharged to the community
(including a boarding home or assisted living facility) or home, then Section A2100 was to be coded one
(1), and if the resident was discharged to an acute care hospital, then Section A2100 was to be coded
three (3).
A discharge note for Resident 66, dated April 18, 2023, revealed that the resident was discharged to an
independent living facility.
A discharge MDS assessment for Resident 66, dated April 18, 2023, revealed that Section A2100 was
coded three (3), indicating that the resident was discharged to an acute care hospital.
Interview with Director of Risk Management on May 24, 2023, at 3:40 p.m. confirmed that Section A2100 of
Resident 66's discharge MDS assessment of April 18, 2023, was not accurate and should have been
coded to indicate that the resident was discharged to the community.
The RAI User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments
(mandated assessments of a resident's abilities and care needs), dated October 2019, revealed that for a
resident with ability to hear, Section B0300 (Hearing Aid) was to be coded as one (1) if the resident used a
hearing aid.
A nursing admission screening observation note for Resident 75, dated May 8, 2023, indicated that the
resident was admitted to the facility and there was no documentation of hearing aids being present on
admission.
Review of an admission MDS assessment, dated May 14, 2023, revealed that Section B0300 (Hearing Aid)
was marked with a (1) yes.
A witness statement, dated May 22, 2023, by the RNAC revealed that Resident 75 stated she wore hearing
aides but had left them at home. The resident did not have hearing aides in place at the time the interview
took place in her room. Resident 75 was in her wheelchair at bedside, was alert, and answered all
questions appropriately.
Interview with the Nursing Home Administator on May 25, 2023, at 10:32 a.m. confirmed that Section
B0300 of Resident 75's MDS assessment of May 14, 2023, was not accurate, as the facility was not able to
determine if the Resident 75 was admitted with hearing aids.
28 Pa. Code 211.5(f) Clinical records.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396021
If continuation sheet
Page 3 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redstone Highlands Health Care
6 Garden Center Drive
Greensburg, PA 15601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being
admitted
Based on review of policies and clinical records, as well as staff interviews, it was determined that the
facility failed to ensure that a baseline care plan was developed and implemented, and that a written
summary of the baseline care plan was provided to the resident and/or the resident's representative for
three of 41 residents reviewed (Residents 77, 78, 80) who were admitted on or after May 15, 2023.
Findings include:
The facility's policy regarding care plans, dated March 13, 2023, revealed that the licensed nurse will initiate
a baseline care plan upon admission to facility and complete within 48 hours. The care plan will include the
minimum healthcare information necessary to properly care for a resident including, but not limited to initial
goals based on admission orders, physician's orders, dietary orders, therapy orders, social services. The
facility may develop a comprehensive care plan in place of the baseline care plan if developed within 48
hours. The facility will provide the resident and their representative with a summary of the baseline care
plan that includes but is not limited to the initial goals of the resident, a summary of the resident's
medications and dietary instructions, any services and treatments to be administered by the facility and
personnel acting on behalf of the facility, and any updated information based on the details of the
comprehensive care plan, as necessary.
A diagnosis list for Resident 77, dated May 18, 2023, revealed that the resident had a diagnosis which
included dependence on renal dialysis (mechanical process that cleanses the blood when the kidneys are
not functioning properly), end stage renal disease (kidney failure), and Type I diabetes (the pancreas makes
little or no insulin) .
Physician's orders for Resident 77, dated May 15, 2023, included an order for the resident to receive
Calmoseptine ointment (a skin treatment) to the coccyx (tail bone) every day for impaired skin
Physician's orders for Resident 77, dated May 18, 2023, included an order for the resident to receive
Humalog (a type of insulin) per sliding scale (the amount of insulin given depends of the level of the
resident's blood sugar level). Physician's orders for Resident 77, dated May 18, 2023, included an order for
the resident to receive 18 units of Glargine (a type of insulin) once a day.
Physician's orders for Resident 77, dated May 18, 2023, included an order for the resident to receive 5
milligrams of Apixaban (anticoagulant/blood thinning medication) twice a day.
A nursing note for Resident 77, dated May 18, 2023, indicated that the resident had redness and
excoriation noted to the coccyx and buttocks, with an open area to right buttocks measuring 0.5 x 0.2
centimeters (cm).
A nursing note for Resident 77, dated May 19, 2023, indicated that the resident was at dialysis and
medication would be administered upon return.
There was no documented evidence that Resident 77's baseline care plan (includes the minimum
healthcare information necessary to properly care for a resident), dated May 18, 2023, included information
about the resident's care needs related to the use of insulin, dialysis, and impaired skin areas to the
buttocks.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396021
If continuation sheet
Page 4 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redstone Highlands Health Care
6 Garden Center Drive
Greensburg, PA 15601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Interview with the Director of Nursing on May 23, 2023, at 1:34 p.m. confirmed there was no baseline care
plan for Resident 77's dialysis needs related to kidney failure, the use of insulin for Type I diabetes, the use
of anticoagulant medication, or for the care and treatment of a skin impairment.
A diagnosis list for Resident 78, dated May 15, 2023, revealed that the resident had a diagnosis which
included Type 2 diabetes (a condition that happens because of a problem in the way the body regulates
and uses sugar as a fuel) and anxiety.
Physician's orders for Resident 78, dated May 15, 2023, included an order for the resident to receive one
50 milligram (mg) tablet of Trazadone (a medication to treat depression) at bedtime.
Physician's orders for Resident 78, dated May 15, 2023, included an order for the resident to receive
Novolog 70/30 (a type of insulin) per sliding scale (the amount of insulin given depends of the level of the
resident's blood sugar level).
There was no documented evidence that Resident 78's baseline care plan (includes the minimum
healthcare information necessary to properly care for a resident), dated May 15, 2023, included information
about the resident's care needs related to the use of antidepressant's and insulin, and there was no
documented evidence that the resident and/or the resident's representative received a written summary of
the baseline care plan.
A diagnosis list for Resident 80, dated May 18, 2023, revealed that the resident had a diagnosis which
included anxiety and hypothyroidism (when the thyroid gland does not make enough thyroid hormones to
meet your body's needs).
Physician's orders for Resident 80, dated May 18, 2023, included an order for the resident to receive 30 mg
injection of Enoxaparin Sodium (a blood thinner) one time a day.
Physician's orders for Resident 80, dated May 18, 2023, included an order for the resident to receive one
50 mg tablet of Sertraline (a medication to treat anxiety) one time a day.
Physician's orders for Resident 80, dated May 18, 2023, included an order for the resident to receive one
15 mg tablet of Temazepam (a medication to treat anxiety) at bedtime.
Physician's orders for Resident 80, dated May 18, 2023, included an order for the resident to receive one
50 microgram (mcg) tablet of Synthroid (a medication to treat hypothyroidism) one time per day.
There was no documented evidence that Resident 80's baseline care plan, dated May 18, 2023, included
information about the resident's care needs related to the use of hypothyroid, anticoagulant (blood
thinners), and antianxiety medications, and there was no documented evidence that the resident and/or the
resident's representative received a written summary of the baseline care plan.
Interview with the Director of Healthcare Navigation on May 23, 2023, at 1:35 p.m. confirmed that Resident
78's baseline care plan did not include the use of antidepressant's and insulin, and that Resident 80's
baseline care plan did not include the use of hypothyroid, anticoagulants, and antianxiety medications
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396021
If continuation sheet
Page 5 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redstone Highlands Health Care
6 Garden Center Drive
Greensburg, PA 15601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0655
Level of Harm - Minimal harm
or potential for actual harm
Interview with the Nursing Home Administrator on May 24, 2023, at 8:10 a.m. confirmed that there was no
documented evidence that Residents 78 and 80 and/or their residents' responsible parties received a
written summary of the residents' baseline care plan.
28 Pa. Code 211.11(e) Resident care plan.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396021
If continuation sheet
Page 6 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redstone Highlands Health Care
6 Garden Center Drive
Greensburg, PA 15601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
Based on clinical record reviews, as well as resident and staff interviews, it was determined that the facility
failed to develop comprehensive care plans that included specific and individualized preferences regarding
health care needs, oxygen needs, diabetes, and activities for four of 41 residents reviewed (Residents 12,
16, 20, 22).
Findings include:
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and
care needs) for Resident 12, dated April 5, 2023, revealed that the resident was cognitively intact, required
extensive assistance of staff for bed mobility, transfers, dressing, toileting, and hygiene and had diagnosis
that included atrial fibrillation (rapid heart beat), hypertension (high blood pressure), and Type 2 diabetes.
Physician's orders for Resident 12, dated April 29, 2023, included an order for the resident to receive 25
milligrams of Sertraline (antidepressant medication) once a day for depression.
Physician's orders for Resident 12, dated April 29, 2023, included an order for the resident to receive 5
milligrams of Eliquis (anticoagulant medication) twice a day for hypertension. Physician's orders for
Resident 12, dated April 29, 2023, included an order for the resident to receive 40 milligrams of Furosemide
(diuretic medication) once a day for hypertension.
Physician's orders for Resident 12, dated April 29, 2023, included an order for the resident to receive 1000
milligrams of metformin (diabetic medication) twice a day for Type 2 diabetes.
Physician's orders for Resident 12, dated May 6, 2023, included an order for the resident to receive Lispro
(a type of insulin) per sliding scale (the amount of insulin given depends of the level of the resident's blood
sugar level).
Interview with the Director of Health Care Navigator on May 24, 2023, at 2:16 p.m. confirmed that Resident
12 did not have care plans developed for the care and treatment of Type 2 diabetes, hypertension,
depression, and the use of anticoagulant medications and should have been.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and
care needs) for Resident 16, dated February 21, 2023, revealed that the resident was cognitively intact,
required extensive assistance with daily care needs, used supplemental oxygen, and had diagnosis that
included chronic respiratory failure.
Physician's order for Resident 16, dated March 11, 2023, included for the resident to use Continuous
Positive Airway Pressure (CPAP-device used to keep breathing airways open while you sleep) on at
bedtime and off in the morning.
An interview with the Director of Nursing on May 23, 2023, at 10:14 a.m. confirmed that as of May 23,
2023, there was no care plan developed regarding Resident 16's use of a CPAP device.
A quarterly MDS assessment for Resident 20, dated May 3, 2023, revealed that the resident was
cognitively intact and had diagnoses that included diabetes with insulin dependence. There was no
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396021
If continuation sheet
Page 7 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redstone Highlands Health Care
6 Garden Center Drive
Greensburg, PA 15601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
documented evidence that the resident's care plan, which was initiated on July 15, 2022, included a care
plan for diabetes.
Interview with the Director of Nursing on May 23, 2023 at 1:32 p.m. confirmed that Resident 20's care plan
was not individualized regarding the resident's diabetes, and it should have been.
Residents Affected - Some
A quarterly MDS assessment for Resident 22, dated March 16, 2023, revealed that the resident was
cognitively intact and required extensive assistance from staff for daily care needs.
An interview with Resident 22 on May 21, 2023, at 10:02 a.m. revealed that she would like more activities to
be scheduled, especially on the weekends when there currently are none. There was no documented
evidence that the resident's care plan, which was initiated January 24, 2021, included the resident's
preferences regarding activities.
Interview with the Activities Director on May 24, 2023 at 1:59 p.m. confirmed that Resident 22's care plan
was not individualized regarding the resident's preference for activities, and it should have been.
28 Pa. Code 211.11(d) Resident care plan.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396021
If continuation sheet
Page 8 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redstone Highlands Health Care
6 Garden Center Drive
Greensburg, PA 15601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
Based 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 41 residents reviewed (Residents 16, 20).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and
care needs) for Resident 16, dated February 21, 2023, revealed that the resident was cognitively intact,
required extensive assistance with daily care needs, used supplemental oxygen, and had diagnoses that
included chronic respiratory failure.
Resident 16's care plan, dated February 16, 2023, revealed a focus for having a urinary tract infection and
antibiotic use; however, the resident did not have a urinary tract infection and was not receiving antibiotics
on May 21, 2023.
An interview with the Director of Nursing on May 23, 2023, at 10:14 a.m. confirmed that Resident 16 did not
have a urinary tract infection and was not being treated with antibiotics, and the resident's care plan was
not updated as it should have been.
A quarterly MDS assessment for Resident 20, dated May 3, 2023, revealed that the resident was
cognitively intact and required staff assistance for daily care needs. Resident 20's care plan, dated
December 16, 2022, indicated that the resident had a leg wound infection and was taking an antibiotic.
However, as of May 24, 2023, the resident had completed the antibiotics and her leg wound had healed.
Interview with the Director of Nursing on May 23, 2023, at 1:32 p.m. confirmed that Residents 16 and 20
were no longer receiving antibiotic medications and that their infections were resolved. He confirmed that
the care plans for Residents 16 and 20 were not revised to reflect that their infections were resolved and
that they should have been.
28 Pa. Code 211.11(d) Resident care plan.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396021
If continuation sheet
Page 9 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redstone Highlands Health Care
6 Garden Center Drive
Greensburg, PA 15601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of Pennsylvania's Nursing Practice Act, facility policy, and clinical record reviews, as well
as staff interviews, it was determined that the facility failed to ensure that a professional (registered) nurse
assessed a resident after a change in condition for two of 41 residents reviewed (Residents 12, 15).
Residents Affected - Few
Findings include:
The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing 21.11
(a)(1)(2)(4) indicated that the registered nurse was responsible for assessing human responses and plans,
implementing nursing care, analyzing/comparing data with the norm in determining care needs, and
carrying out nursing care actions that promote, maintain and restore the well-being of individuals.
The facility's policy regarding change in condition, dated March 13, 2023, revealed that prior to notifying the
physician or health care provider, the nurse will make detailed observations and gather relevant and
pertinent information. The nurse will notify the physician when there was an accident or incident or a
discovery of injuries of an unknown source.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and
care needs) for Resident 12, dated April 5, 2023, revealed that the resident was cognitively intact, required
extensive assistance of staff for bed mobility, transfers, dressing, toileting, and hygiene, and was at risk for
developing pressure ulcers (skin impaired caused by pressure). A care plan for Resident 12, initiated on
May 10, 2023, revealed that he had a pressure ulcer on his left heel.
A nursing note for Resident 12, dated May 6, 2023, and written by a licensed practical nurse, indicated that
during a weekly skin check a new area was noted on the left heel measuring 1.5 centimeters (cm) x 1.0 cm.
The wound bed was pink/yellow and the surrounding skin was pink. The area was cleaned with normal
saline solution, an application of medihoney was applied, and then a small foam dressing was applied. The
wound nurse was notified and created new wound care orders. There was no documented evidence in
Resident 12's clinical record to indicate that the resident was assessed by a registered nurse when the new
pressure ulcer was identified.
Interview with the Director of Health Care Navigator on May 24, 2023, at 1:35 p.m. confirmed that a
registered nurse did not assess after the identification of a new pressure ulcer and should have.
A quarterly MDS assessment for Resident 15, dated April 1, 2023, revealed that the resident was
cognitively impaired and required extensive assistance from staff for her daily care needs.
A nursing note for Resident 15, dated April 21, 2023, indicated that the resident's family was notified
regarding an incident that happened the previous weekend where the resident's head was bumped on a
mechanical lift (a mechanical device used to lift a resident from another position) during a transfer. There
was no documented evidence that the resident was assessed by a registered nurse when the incident
occurred.
Interview with the Director of Nursing on May 24, 2023, at 2:29 p.m. confirmed that a registered nurse did
not assess Resident 15 after she was hit in the head with the mechanical lift and they should have.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396021
If continuation sheet
Page 10 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redstone Highlands Health Care
6 Garden Center Drive
Greensburg, PA 15601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0658
28 Pa. Code 211.12(d)(1)(5) Nursing services.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396021
If continuation sheet
Page 11 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redstone Highlands Health Care
6 Garden Center Drive
Greensburg, PA 15601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that
dependent residents were provided with the necessary services to maintain personal grooming, by failing to
keep a female resident free of facial hair for one of 41 residents reviewed (Resident 45).
Residents Affected - Few
Findings include:
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and
care needs) for Resident 45, dated April 27, 2023, revealed that the resident was cognitively impaired,
required extensive assistance from staff for personal hygiene, and had diagnosis that included complete
atrioventricular block (a type of heart rhythm disorder).
Observations of Resident 45 on May 21, 22, and 23, 2023, during lunch meal service revealed the resident
sitting in her wheelchair in the dining room with other residents, visitors, and staff around her, with multiple
light-colored hairs, approximately one quarter of an inch long on her chin. There was no documentation in
the clinical record to indicate that the resident refused to have personal hygiene or shaving completed.
Observations on May 24, 2023, at 10:08 a.m. revealed that she was sitting in her wheelchair in the hallway
with no noticeable facial hair.
An interview with Nursing Assistant 1 on May 23, 2023, at 12:20 p.m. confirmed that facial hair was present
on Resident 45's chin and that it should not be there.
An interview with the Director of Nursing on May 23, 2023, at 1:07 p.m. confirmed that female residents
should not have noticeable hair on their chin for three consecutive days.
28 Pa. Code 211.12(d)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396021
If continuation sheet
Page 12 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redstone Highlands Health Care
6 Garden Center Drive
Greensburg, PA 15601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0679
Provide activities to meet all resident's needs.
Level of Harm - Minimal harm
or potential for actual harm
Based on a review of facility policies and clinical records, as well as resident and staff interviews, it was
determined that the facility failed to provide adequate, ongoing activities designed to meet the needs of
residents for four of 41 residents reviewed (Residents 8, 20, 22, 48).
Residents Affected - Few
Findings include:
The facility's activity policy, dated March 13, 2023, indicated that they would provide activities to meet the
resident's needs.
A review of the monthly activity calendar, dated March, April, and May 2023, revealed that on Sundays they
only have an interfaith service at 2:30 p.m. The calendar revealed that on Monday, Wednesday, Thursday,
and Friday, there were activities from 9:30 a.m. through 3:00 p.m., and on Tuesday activities were from 9:30
a.m. through 3:00 p.m. and one activity at 6:00 p.m. Saturday revealed that there was a movie at 1:00 p.m.
and on the second Saturday of the month there were games at 10:00 a.m. and bingo at 2:00 p.m.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and
care needs) for Resident 8, dated December 13, 2022, revealed that the resident was cognitively intact and
that it was very important to her to do things with groups of people, to do her favorite activities, and to go
outside to get fresh air when the weather is good. A care plan for the resident, dated December 6, 2022,
revealed that staff was to provide engagement opportunities through a combination of live broadcasting of
activities into resident rooms, independent self-directed opportunities, as well as individual interventions.
An initial activities review for Resident 8, dated December 7, 2022, revealed that the resident likes to watch
game shows, enjoys word searches, loves to play bingo, and likes to sew. The resident wishes to participate
in activities while in the home and wishes to participate in group activities, go on outings, have one-to-one
with staff, and also likes to have independent activities.
An interview with Resident 8 on May 22, 2023, at 1:22 p.m. revealed that the resident is frustrated that
there is nothing to do on the weekends or in the evenings. She said it is very boring sitting around all day
waiting for the time to pass. There is nothing good on TV and she does not care to sit and watch movies all
day. She and some other residents have asked multiple times for structured activities on the weekends and
have been told that they could go play a game or cards, but there is no one to set things up for them and
they are all unable to do it themselves.
A comprehensive MDS assessment for Resident 20, dated May 3, 2023, revealed that the resident was
cognitively intact and required staff assistance for her daily care needs. Resident 20's care plan, dated July
15, 2022, indicated that her activity interests would be assessed upon her admission to the facility.
An interview with Resident 20 on May 21, 2023, at 2:36 p.m. revealed that she is bored on the weekends.
She said that she has some friends and they do like to play games, but she would prefer at least one or two
organized activities on the weekends to help pass the time. She further stated she did not understand why
they could not have bingo more than one time a week. She stated it is one hour long and it is the fastest
hour of her week.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396021
If continuation sheet
Page 13 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redstone Highlands Health Care
6 Garden Center Drive
Greensburg, PA 15601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0679
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
A quarterly MDS assessment for Resident 22, dated March 16, 2023, revealed that the resident was
cognitively intact and required staff assistance for her daily care needs. Resident 22's care plan, revised
March 16, 2023, did not include a care plan related to the resident's activity preferences.
An interview with Resident 22 on May 21, 2023, at 10:02 a.m. revealed that she wanted more activities
during the week and especially on the weekends. She stated there were currently no weekend activities
other than a movie and she preferred organized or structured activities to attend.
A quarterly MDS assessment for Resident 48, dated April 28, 2023, revealed that the resident was
cognitively intact and required staff assistance for her daily care needs. Resident 48's care plan, dated
August 28, 2018, revealed that she was dependent on staff and family for activities and that she should be
provided an activity calendar.
An interview with Resident 48 on May 21, 2023, at 2:15 p.m. revealed that the facility did not have enough
activities for her to participate in. She stated that there was nothing to do in the evenings or on the
weekends. She further stated that she would prefer more structured activities on the weekends and in the
evenings after supper.
Interview with the Activity Director on May 24, 2023, at 1:59 p.m. revealed that there is one staff member
who works one Saturday a month and does one organized activity on that day. He said that there are
movies that can play for the residents on the weekends, but no organized activities.
Interview with the Nursing Home Administrator on May 24, 2023, at 2:48 p.m. revealed that the residents
could take themselves, if able, to the personal care side of the facility and participate in their activities;
however, the residents may or may not be aware of that.
28 Pa. Code 211.11(d) Resident care plan.
28 Pa. Code 211.12(d)(3) Nursing services.
28 Pa. Code 211.12(d)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396021
If continuation sheet
Page 14 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redstone Highlands Health Care
6 Garden Center Drive
Greensburg, PA 15601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to
ensure that a physician was notified of low blood pressures and medications being held for one of 41
residents reviewed (Resident 16).
Residents Affected - Few
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and
care needs) for Resident 16, dated February 21, 2023, revealed that the resident was cognitively intact,
required extensive assistance with daily care needs, used supplemental oxygen, and had diagnosis that
included chronic respiratory failure.
Physician's orders for Resident 16, dated February 14, 2023, included for the resident to receive 25
milligrams (mg) of Metoprolol Tartrate (used to treat high blood pressure) two times a day for hypertensive
heart disease (heart disease caused by high blood pressure).
A nurse's note for Resident 16, dated March 3, 2023, at 6:51 a.m. revealed that the resident had a low
blood pressure of 86/50 millimeters of mercury (mm/Hg).
Review of the Medication Administration Record (MAR) for Resident 16 for March 2023 revealed
documentation of the following low blood pressures: March 2 on night shift was 86/50 mm/Hg; March 6 on
evening shift was 99/60 mm/Hg; March 7 on day shift was 98/62 mm/Hg; March 7 on evening shift was
98/62 mm/Hg; March 7 on night shift was 91/60 mm/Hg; and March 8 on night shift was 99/65 mm/Hg.
Review of the MAR also revealed that the resident's metoprolol was not administered on March 1 at 8:00
a.m. and March 5, 6, and 7 at 10:00 p.m.
There is no documented evidence in Resident 16's clinical record to indicate that the physician was notified
of the above-mentioned low blood pressures or the Metoprolol doses that were not administered.
An interview with the Director of Nursing on May 23, 2023, at 10:14 a.m. confirmed that there was no
documented evidence that the physician was notified of Resident 16's low blood pressures or the
Metoprolol doses that were not administered.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396021
If continuation sheet
Page 15 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redstone Highlands Health Care
6 Garden Center Drive
Greensburg, PA 15601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
Based on a review of facility policy, clinical records, and staff interviews, it was determined that the facility
failed to ensure the provision of restorative nursing to maintain and/or to prevent a decline in range of
motion for three of 41 residents reviewed (Residents 5, 17, 45).
Findings include:
The facility's policy regarding Restorative Nursing, dated March 13, 2023, revealed that residents will
receive restorative nursing care as needed to help promote optimal safety and independence.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and
care needs) for Resident 5, dated April 13, 2023, revealed that the resident was cognitively impaired,
required extensive assist assistance from staff for personal hygiene, and had diagnosis that included
dementia.
Resident 5's care plan, dated November 26, 2020, indicated that the resident was at risk for decline in
functional ability and she will perform active assisted range of motion (AAROM) to all joints to maintain
strength, endurance and functional ROM abilities once daily as tolerated. The resident's care plan included
an intervention for the resident to receive AAROM to all joints to decrease the risk of contracture and
maintain/improve range of motion ability once daily.
There was no documented evidence of restorative range of motion being completed for Resident 5, and
there was no evidence that the resident's range of motion had been assessed to determine if the resident
was participating in the restorative nursing program.
An annual MDS assessment for Resident 17, dated April 26, 2023, indicated that the resident was
cognitively impaired and required assistance from staff for daily care needs. Resident 17's care plan, dated
June 15, 2020, indicated that the resident was at risk for decline in functional ability and she will maintain
mobility and endurance to achieve maximum level of independence/safety without evidence of increased
falls by ambulating once daily as tolerated. The resident's care plan, dated June 15, 2020, revealed that the
resident would walk 80 feet with a minimum assistance of one staff and a wheeled walker. The resident's
task list indicated that the resident was to walk 10 feet every shift, walk 150 feet with two turns, roll right and
left and return to lying on back on the bed, would wheel 150 feet once seated in wheelchair/scooter, and
wheel 50 feet with two turns once seated in wheelchair/scooter.
There was no documented evidence in the clinical record of restorative programs being provided to
Resident 17. The resident's task list was not completed consistently and there was no evidence that the
resident's ability to walk, turn herself in bed, or wheel herself in her chair had been assessed to determine if
the resident was participating in the restorative nursing program.
An annual MDS assessment for Resident 45, dated April 27, 2023, revealed that the resident was
cognitively impaired, required extensive assistance from staff for personal hygiene, and had diagnosis that
included complete atrioventricular block (a type of heart rhythm disorder).
Resident 45's care plan, revised May 11, 2023, indicated that the resident was at risk for decline in
functional ability and she will maintain mobility and endurance to achieve maximum level of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396021
If continuation sheet
Page 16 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redstone Highlands Health Care
6 Garden Center Drive
Greensburg, PA 15601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
independence/safety without evidence of increased falls by ambulating once daily as tolerated. The
resident's care plan intervention, dated April 22, 2021, revealed that the resident would walk 50 feet with a
minimum assistance of one staff and a wheeled walker with a wheelchair following her. The resident's task
list indicated that the resident was to be walked 10 feet every shift, walk 150 feet with two turns.
There was no documented evidence in the clinical record of restorative ambulation for Resident 45. The
resident's task list was not completed consistently and there was no evidence that the resident's ability to
walk had been assessed to determine if the resident was participating in the restorative nursing program.
Interview with the Health Navigator on May 24, 2023, at 10:00 a.m. confirmed that the facility no longer had
a full restorative program and that there was no clear way to determine if a resident is participating in a
restorative nursing program or if they are unable to participate.
28 Pa. Code 211.12(d)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396021
If continuation sheet
Page 17 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redstone Highlands Health Care
6 Garden Center Drive
Greensburg, PA 15601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of facility policies and clinical record reviews, as well as staff interviews, it was determined
that the facility failed to ensure that respiratory equipment (CPAP) was cleaned regularly for three of 41
residents reviewed (Residents 16, 20, 53).
Residents Affected - Few
Findings include:
The facility's policy for Continuous Positive Air Pressure (CPAP), dated March 13, 2023, indicated that the
mask or nasal pillow on CPAP devices be cleaned daily by placing in warm, soapy water and
soaking/agitating, and then rinsed with warm and allowed to air dry between uses. The CPAP tubing should
be cleaned weekly by placing in warm soapy water and soaking/agitating, and then rinsed with warm and
allowed to air dry between uses. The CPAP machine and headgear should be cleaned as needed and the
CPAP filter should be cleaned monthly to remove dust and debris.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and
care needs) for Resident 16, dated February 21, 2023, revealed that the resident was cognitively intact,
required extensive assistance with daily care needs, used supplemental oxygen, and had diagnosis that
included chronic respiratory failure.
There was no documented evidence that Resident 16 had a physician's order or a care plan to clean or
maintain her CPAP device.
Interview with Resident 16 on May 21, 2023, at 11:30 a.m. revealed that she wears a CPAP device at night
and that a new mask was ordered for her due to irritation on the bridge of her nose from the mask she is
currently using.
Interview with the Director of Nursing on May 23, 2023, confirmed that there was no documentation of
Resident 16's CPAP device being cleaned prior to May 23, 2023.
A quarterly MDS assessment for Resident 20, dated May 3, 2023, revealed that the resident was
cognitively intact and had diagnoses that included Chronic Obstructive Pulmonary Disease (COPD, a
breathing disorder).
Interview with Resident 20 on May 21, 2023, at 2:36 p.m. revealed that she wears a CPAP device at night
and that staff help her to put the machine on when it is time for her to go to sleep.
There was no documented evidence that Resident 20 had a physician's order to wear her CPAP device at
night or to clean or maintain her CPAP device.
Interview with the Nursing Home Administrator on May 23, 2023, at 11:30 a.m. confirmed that Resident 20
did not have a physician's order for the CPAP device or to maintain or clean the CPAP device and she
should have.
A quarterly MDS assessment for Resident 53, dated May 1, 2023, revealed that the resident was
cognitively intact and required assistance from staff for daily care needs. Physician's orders for Resident 53
included an order, dated May 1, 2023, for the resident to self apply his CPAP at night. The resident's care
plan, dated February 10, 2021, indicated that the resident had respiratory failure and wore a CPAP nightly.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396021
If continuation sheet
Page 18 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redstone Highlands Health Care
6 Garden Center Drive
Greensburg, PA 15601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
There was no documented evidence that Resident 53's CPAP was cleaned regularly.
Level of Harm - Minimal harm
or potential for actual harm
An interview with the Director of Nursing on May 23, 2023, at 10:14 a.m. revealed that there was no
documented evidence that Residents 16, 20, and 53's CPAP apparatuses were cleaned or maintained
regularly.
Residents Affected - Few
28 Pa. Code 211.12(d)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396021
If continuation sheet
Page 19 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redstone Highlands Health Care
6 Garden Center Drive
Greensburg, PA 15601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0698
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of policies and clinical records, as well as observations and resident and staff interviews, it
was determined that the facility failed to obtain physician's orders for dialysis or for the care and monitoring
of dialysis sites for one of 41 residents reviewed (Resident 77).
Residents Affected - Few
Findings include:
The facility's policy regarding care for residents who receive dialysis (mechanical process that cleanses the
blood when the kidneys are not functioning properly), dated March 13, 2023, revealed that the hemodialysis
procedure would be under the direct responsibility and supervision of the contracted dialysis agency.
The outpatient dialysis service agreement, signed August 23, 2013, indicated that both the facility and
outpatient dialysis facility would mutually develop a written protocol governing specific reponsibilities,
policies, and procedures to be used in rendering dialysis services to residents at the dialysis unit, including
but not limited to, the development and implementation of a resident's care plan relative to the provision of
dialysis services.
A nursing note for Resident 77, dated May 18, 2023, indicated that the resident was admitted to the facility
with a right subclavian catheter (a deep central vein from the axillary vein that joins the internal jugular vein
under the clavicle) with a dressing that was dry and intact. A nursing note for Resident 77, dated May 21,
2023, indicated that the resident had a right chest double lumen dialysis site with a dressing in place. A
nursing note for Resident 77, dated May 19, 2023, indicated that the resident was at dialysis and
medication would be administered upon return.
Interview with Resident 77 on May 23, 2023, at 12:04 a.m. revealed that she went to dialysis on May 22,
2023; she received dialysis through the port on her chest; and she has a fistula (surgical dialysis access
site) on her right arm, but it has not been accessed.
There was no documented evidence that staff monitored the dialysis site, and there was no documented
evidence that physician's orders were obtained for hemodialysis services or for monitoring the access sites.
Interview with the Director of Nursing on May 23, 2023, at 1:34 p.m. confirmed that there was no
documented evidence that physician's orders for dialysis services or for monitoring Resident 77's s dialysis
access sites were obtained, and no documented evidence that the dialysis sites were being monitored.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396021
If continuation sheet
Page 20 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redstone Highlands Health Care
6 Garden Center Drive
Greensburg, PA 15601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0773
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the
results.
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to
obtain a physician's order for an invasive procedure to collect a specimen for a laboratory test for one of 41
residents reviewed (Resident 83).
Findings include:
An admission nursing note for Resident 83, dated April 29, 2023, revealed that the resident was confused
with a diagnosis that included dementia and was continent of bowel and bladder.
A nursing note for Resident 83, dated May 4, 2023, revealed that the resident's daughter reported to staff
that the resident was having increased hallucinations. Staff were waiting for the resident to urinate so that it
could be collected for testing, but the resident did not void. Resident 83 was straight catheterized (an
invasive procedure in which a plastic tube is inserted into the bladder) to obtain the urine.
There was no documented evidence in the clinical record to indicate that staff obtained a physician's order
to collect Resident 83's urine specimen via catheterization.
Interview with the Director of Health Navigation on May 24, 2023, at 8:50 a.m. confirmed that there was no
evidence that a physician's order was obtained for Resident 83 to be straight catheterized in order to obtain
the urine specimen.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396021
If continuation sheet
Page 21 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redstone Highlands Health Care
6 Garden Center Drive
Greensburg, PA 15601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on review of policies, as well as observations and staff interviews, it was determined that the facility
failed to ensure that food items were stored in accordance with professional standards for food service
safety in the walk-in freezer, walk-in coolers, and the dry storage in the main kitchen.
Findings include:
The facility's policy regarding labeling and dating food, dated March 13, 2023, indicated that all foods were
labeled with the name, use by dated, prepared and opened date to ensure food safety. The facility's policy
regarding food storage, dated March 13, 2023, revealed that all food stored in dry storage would be at least
six inches above the floor. Staff are to cover, label, and date unused portions and opened packages. Foods
past the use by, sell by, best by, or enjoy by dates should be discarded. Raw foods and cooked foods should
be separated with cooked foods being stored above raw foods.
Observations in Walk-In Refrigerator 3 on May 21, 2023, at 9:44 a.m. revealed an opened and undated
quart of chocolate milk with a best-by date of May 18, 2023. Observations in Walk-In Refrigerator 2 on May
21, 2023, at 9:49 a.m. revealed a bowl of staff-prepared ambrosia salad being stored under a large pan of
raw beef tenderloin, and a 40-ounce opened and undated package of hard salami. Observations in the
walk-in freezer on May 21, 2023, at 9:52 a.m. revealed one opened and undated bag of frozen chef gold
vegetable blend and a 20-pound box of mixed vegetables that were open and exposed to air and undated.
Observations of the dry storage area on May 21, 2023, at 9:54 a.m. revealed a box of Frito Lay individual
smart popcorn bags and a box of snack pack pudding stored directly on the floor.
Interview with the Dietary Manager on May 21, 2023, during the tour of the food storage areas, confirmed
that expired foods should be disposed of; prepared foods should not be stored under raw meats; all food
packages should be labeled, dated, and sealed after opening; and dry foods should be stored above the
floor.
28 Pa. Code 211.6(f) Dietary services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396021
If continuation sheet
Page 22 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redstone Highlands Health Care
6 Garden Center Drive
Greensburg, PA 15601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0867
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop
corrective plans of action.
Based 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.
Findings include:
The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of
Health) survey ending June 23, 2022, and a complaint investigation survey ending July 29, 2022, revealed
that the facility developed plans of correction that included quality assurance systems to ensure that the
facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending
May 24, 2023, identified repeated deficiencies related to the accuracy of Minimum Data Set (MDS)
assessments (mandated assessment of a resident's abilities and care needs), revision of comprehensive
care plans, and meeting professional standards of practice.
The facility's plan of correction for a deficiency regarding the accuracy of assessments, cited during the
survey ending June 23, 2022, revealed that the facility would complete audits and report the results of the
audits to the QAPI committee for review. The results of the current survey, cited under F641, revealed that
the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with
regulations regarding the accuracy of assessments.
The facility's plan of correction for a deficiency regarding the development of comprehensive care plans,
cited during the survey ending June 23, 2022, revealed that the facility would complete audits and report
the results of the audits to the QAPI committee for review. The results of the current survey, cited under
F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure
ongoing compliance with regulations regarding the revision of comprehensive care plans.
The facility's plan of correction for a deficiency regarding services meeting professional standards, cited
during the survey ending July 29, 2022, revealed that the facility would complete audits and report the
results of the audits to the QAPI committee for review. The results of the current survey, cited under F658,
revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing
compliance with regulations regarding professional standards.
Refer to F641, F656, F658.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(1) Management.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396021
If continuation sheet
Page 23 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redstone Highlands Health Care
6 Garden Center Drive
Greensburg, PA 15601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0887
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and
staff after education, and properly document each resident and staff member's vaccination status.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review, review of select facility policies and procedures, and staff interview, it was determined
that the facility failed to offer, or provide education regarding the benefits, risks, and potential side effects of
the COVID-19 vaccine for three of five residents reviewed for immunizations (Residents 60, 71, 80).
Findings include:
Review of the policy regarding Infection Control-Vaccination for COVID-19, dated March 13, 2023, indicates
that the facility will educate residents on the risks and benefits of the COVID vaccines, offer to administer
the vaccine, and report vaccination data to Center for Disease Control's (CDC) National Healthcare Safety
Network. Data will be collected upon admission to determine if a resident has been fully vaccinated against
COVID-19. COVID-19 vaccination and handwashing education will be provided upon admission. If
applicable the COVID-19 vaccine or booster will be offered. Nursing will obtain a physician order for the
applicable vaccine; nursing will complete the Vaccine Administration Record Informed Consent for
Vaccination in Long Term Care Facility form and send it to the identified staff who will keep a log of
residents requesting the vaccine. The vaccine will be ordered on Monday, delivered on Thursdays, and
administered on Friday.
Review of the clinical record revealed that Resident 60 was admitted to the facility on [DATE]. A review of
the resident's COVID tracker record done on admission revealed that the resident had previously refused
the COVID vaccine. As of May 24, 2023, there was no documented evidence that the resident was offered
education regarding the risks and benefits of the COVID vaccine or the COVID vaccination.
Review of the clinical record revealed that Resident 71 was admitted to the facility on [DATE]. A review of
the resident's COVID tracker record done on admission revealed that the resident had previously refused
the COVID vaccine. As of May 24, 2023, there was no documented evidence that the resident was offered
education regarding the risks and benefits of the COVID vaccine or the COVID vaccination.
Review of the clinical record revealed that Resident 80 was admitted to the facility on [DATE]. A review of
the resident's COVID tracker record done on admission revealed that the resident had previously refused
the COVID vaccine. As of May 24, 2023, there was no documented evidence that the resident was offered
education regarding the risks and benefits of the COVID vaccine or the COVID vaccination.
Interview with the Director of Nursing on May 24, 2023, at 4:15 p.m. confirmed that there was no
documented evidence that Residents 60, 71 and 80 were offered education regarding the risks and benefits
of the COVID vaccine or the COVID vaccination.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396021
If continuation sheet
Page 24 of 24
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Back to topCitations
15 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F679 - Activities
Provide activities to meet all resident's needs.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F773 - The facility must—
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F887 - Infection control
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
FAQ · About this visit
Common questions about this visit
What happened during the May 24, 2023 survey of Redstone Highlands Health Care?
This was a inspection survey of Redstone Highlands Health Care on May 24, 2023. The surveyor cited 15 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Redstone Highlands Health Care on May 24, 2023?
Yes, 15 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure each resident receives an accurate assessment."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.