Health inspection·October 15, 2025

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 Page 1 of 3 396021 396021 10/15/2025 Redstone Highlands Health Care 6 Garden Center Drive Greensburg, PA 15601

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 396021 Page 2 of 3 396021 10/15/2025 Redstone Highlands Health Care 6 Garden Center Drive Greensburg, PA 15601

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 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. 396021 Page 3 of 3