Care One at Redstone

In the surveyor’s words

From the most serious findings on record at Care One at Redstone, in the surveyor’s own words.

• Actual harm, isolatedF806Oct 22, 2025

  Based on records reviewed, interviews, and observations for one of three sampled residents, (Resident #1) who had a known food allergy to onions, the Facility failed to ensure his/her diet was free from allergens, when on 09/15/25, Resident #1 was served a meal that contained onions, Resident #1 consumed some of the meal, developed signs and symptoms of an allergic reaction, and was transferred to the Hospital Emergency Department (ED) for evaluation of anaphylaxis (a severe, potentially life-threatening allergic reaction) where he/she was admitted for further treatment.Findings include:Review of the Facility's Policy titled Food Allergies and Intolerances, dated as revised August 2017, indicated the following:- Food allergies are immune system responses to allergens (foods).- Residents… […]

• Actual harm, isolatedF684Feb 7, 2023

  Based on interview, policy review, and record review, the facility and its staff failed to ensure quality care and services were provided to one Resident (#161) out of a total sample of 37 Residents. Specifically, the facility failed to: A) monitor and notify the Physician of critical lab values consistent with hypernatremia and acute kidney injury resulting in a hospitalization , and B) identify, address and monitor an unplanned, significant weight loss by failing to re-check weights timely, monitor enteral (a liquid form of nutrition delivered into the digestive system) intake consistently, and implement nutritional interventions to prevent further significant weight loss. […]

• Actual harm, isolatedF686Feb 7, 2023

  Based on observations, interviews, and record review, the facility failed to ensure its staff prevented one Resident (#58), of 10 applicable residents, from developing two pressure injuries/ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin), out of a total sample of 37 residents. Specifically, the facility staff failed to: a) accurately assess the Resident's risk for developing pressure injuries while at the facility for post-operative care after spinal surgery, and b) also accurately assess, document and treat the Resident's pressure injuries. […]

• Actual harm, isolatedF692Feb 7, 2023

  Based on observation, interviews, record and policy review, the facility failed to ensure that staff identified, addressed and monitored significant weight loss of one resident (#82) with unplanned, significant weight loss, out of a sample of 37 residents. Specifically, the facility failed to notify a Physician or Nurse Practitioner of Resident #82's change in condition, recheck weights timely, weigh resident at the frequency ordered by the Physician and implement nutritional interventions to prevent further significant weight loss. Findings include: Resident #82 was admitted to the facility in [DATE], with multiple diagnoses including Alzheimer's Disease, Insulin Dependent Diabetes, and Dysphagia. […]

• No harm, potential for more than minimal, widespreadF812Jun 6, 2024

  Based on observation, interview and policy review, the facility failed to properly follow sanitation and food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service safety. Specifically, the facility failed to: 1. Ensure resident food was prepared and distributed to prevent potential for cross contamination. 2. Ensure beard nets were worn in the food preparation area. Findings include: Review of the facility policy titled Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices, revised December 2008, indicated Food Service employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. […]