Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0689
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on review of policies, manufacturer's operations manual, clinical records, and facility reports, as well
as staff interviews, it was determined that the facility failed to ensure residents' environment remained free
of accident hazards, and failed to ensure adequate interventions and supervision to prevent elopements
which threatened the resident's safety and increased the resident's risk for accidents and bodily injury or
harm for one of three residents identified at risk for elopement (Resident 3). The facility further relied on it's
alarm system to prevent unsupervised exits, which placed residents in immediate jeopardy of the likelihood
of serious bodily injury, harm or death. This deficiency was cited as past non-compliance. Findings
include:The facility policies for elopements and Wander Guards (a bracelet that triggers an alarm and can
lock monitored doors to prevent the resident from leaving unattended), dated July 11, 2025, indicated that
an Elopement Risk Observation would be completed by a licensed nurse upon admission, re-admission,
and/or with any significant change in status whereby an elopement may become an increased possibility.
Upon completion of an Elopement Risk Observation, it would be determined by the charge nurse as to
what interventions would be initiated. Upon determination of appropriate interventional devices to be
utilized to maintain resident safety, a physician order would be obtained for any such device. Upon high risk
determination, the resident would be issued a Wander Guard bracelet to be placed on his/her wrist or
ankle. Placement of the Wander Guard apparatus would assist in alerting interdisciplinary team members
that a resident has, or is attempting to exit the nursing unit. All residents having orders for, or utilizing the
Wander Guard bracelet, would have placement and function assessed every shift while awake and out of
bed to chair. Individual care plans would be updated accordingly. If a resident eloped and was found, staff
were to notify the Nursing Home Administrator, Director of Nursing, Executive Director, [NAME] President of
Quality Services, Director of Building Services, and the responsible party when the resident was found.
Nursing would complete a head to toe assessment, provide appropriate immediate care, if warranted, and
document the findings and details of the episode in the resident's medical record. Nursing staff would
complete a n internal incident report and communicate a shift to shift report for the next 72 hours regarding
the resident's condition. Nursing Administration would notify the State Department of Health following initial
steps to address the emergencyThe operator's manual for the wanderer monitoring system, undated,
indicated that wander monitoring transmitters should be tested daily for proper operation. If a device was in
a low battery state, the battery or device was to be replaced as soon as possible. An annual Minimum Data
Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3,
dated July 1, 2025, indicated that the resident could usually make her self understood and understand
others, was cognitively impaired, used a wander/elopement alarm, and had diagnoses that included
dementia. Current physician's orders for Resident 3, included orders for a wander guard to be used and it's
function and placement checked every shift. A care plan, dated July 11, 2024, indicated the resident was
(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 3
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
10/15/2025
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 0689
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
to use a wander guard and have the placement checked every shift. A social service note, dated April 8,
2025, revealed that Resident 3 required a wander guard due to her making her way down the elevator at
times. An elopement assessment, dated September 2, 2025, revealed that Resident 3 was at risk for
elopement. A nursing note for Resident 3, dated September 16, 2025, at 8:01 p.m. revealed the resident
was escorted back into the building by EMS (Emergency Medical Services) personnel from the back
entrance and she was unable to explain why she was out there. A wander guard was attached to her Broda
chair (specialized wheelchair). A facility investigation, dated September 17, 2025, revealed that on
September 16, 2025, at 2:52 p.m. Resident 3 eloped by accessing the elevator, going down to the ground
floor, headed to personal care, and left the facility. The resident self propels in her wheelchair around the
unit. Administration was notified of the elopement on September 17, 2025, at 8:30 a.m. and upon checking
Resident 3's wander guard, it was noted in the system as of 6:45 a.m. in the morning that her battery status
was low. Resident 3's wander guard was changed immediately upon notification and an elopement
assessment was completed on all residents.A Treatment Administration Record (TAR) for September 2025
revealed that on September 16, 2025, staff charted - for the wander guards functioning for the first, second,
and third shift. A system status report, dated September 16 and 17, 2025, revealed that Resident 3's
wander guard battery status was low for these days.A witness statement from Registered Nurse 1, dated
September 17, 2025, revealed that around 3:50 p.m. EMS brought Resident 3 back to the unit and reported
that she was outside by receiving and she notified the resident's nurse immediately.A witness statement
from Registered Nurse 2, dated September 17, 2025, revealed that she was notified around 4:30- 5:00 p.m.
that EMS had brought Resident 3 back into the facility and she didn't know where she was. It was told that
EMS found the resident outside. She reported that she did not do a physical assessment of the resident or
call the family because she didn't think it was an elopement because the resident wandered. Registered
Nurse 1 told her the phone did not trigger with the wander guard, and Registered Nurse 2 reported that she
did not check the function of the alarm when the resident returned. A witness statement from Registered
Nurse 3, dated September 17, 2025, revealed that Registered Nurse 2 called him around 4:00 p.m. and she
stated that Resident 3 got outside and that EMS brought her back in. She asked what needed done, and
she was told to put a note in and do a full assessment.Interview with the Nursing Home Administrator on
October 15, 2025, at 12:44 p.m. and 1:30 p.m. confirmed that Resident 3 eloped from the building and the
wander guard system did not alarm. He could not get a clear answer from the nurse why she charted the
function of the wander guard as - for the first shift. He indicated that the nurse did not consider the resident
leaving the facility as an elopement; therefore administrative staff were not notified of the incident until the
next day. He confirmed that if the alarm was not functioning properly prior to Resident 3's elopement it
should have been changed, and confirmed that the resident's wander guard had a low battery on
September 16, 2025, when the resident eloped, and it should have been checked/changed after the
resident was returned to the facility. He confirmed that staff did not check the alarm following Resident 3's
elopement and did not implement any new interventions to ensure that Resident 3 did not elope again; until
the morning of September 17, 2025 when he was notified of the elopement.On October 15, 2025, at 3:45
p.m. the Director of Nursing was given the Immediate Jeopardy template and informed that the health and
safety of Resident 3 was placed in Immediate Jeopardy as past non-compliance due to the failure to ensure
that supervision and adequate interventions were in place to prevent elopements while using the wander
guard alarm system.Following the incident on September 16, 2025, the facility's corrective actions
included:Immediately upon discovery on September 17, 2025 Resident 3's wander guard transmitter was
replaced with a new transmitter and checked
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396021
If continuation sheet
Page 2 of 3
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
10/15/2025
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 0689
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
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
at the time of discovery.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. Education was completed on September 18, 2025. 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 which was initiated on September 17, 2025 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. The Immediate Jeopardy was lifted on October 15, 2025, at
5:28 p.m. when it was confirmed that the corrective action plans developed on September 17, 2025, were
completed by September 18, 2025, and that the wander guards were being checked as ordered and
replaced as needed, and all residents that used the wander guard system had no elopements. The facility's
date of compliance was September 18, 2025.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code
201.18(b)(1)(e)(1) Management.28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(5)
Nursing services.
Event ID:
Facility ID:
396021
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation 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.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the October 15, 2025 survey of Redstone Highlands Health Care?
This was a inspection survey of Redstone Highlands Health Care on October 15, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Redstone Highlands Health Care on October 15, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
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
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.