Redstone Highlands Health Care

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Oct 15, 2025

  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. […]

• Actual harm, isolatedF600Mar 12, 2026

  Based on review of policies, investigation reports, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of four residents reviewed (Residents 3), resulting in a fracture. This deficiency is being cited as Past Non-Compliance. The facility's policy for Abuse Prohibition dated July 11, 2025, indicated that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. […]

• Actual harm, isolatedF689Mar 12, 2026

  Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's environment remained free of accident hazards by failing to ensure care-planned interventions were in place for one of four residents reviewed (Resident 3) who required assistance with transferring from a bed to a chair. This deficiency is being cited as Past Non-Compliance. Findings include:The facility's policy for Using the Kardex in PCC: a quick guide, dated July 11, 2025, indicated that the Kardex (nursing documentation system used for quick, daily reference of patient care information, such as medications, allergies, activity levels, and treatment plans) is an essential tool within PCC (Point Click Care- type of electronic… […]

• Actual harm, isolatedF760Aug 5, 2025

  Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for one of four residents reviewed (Resident 2) resulting in a critically abnormal blood clotting time.Findings include:An admission Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's abilities and care needs) for Resident 2 dated April 20, 2025, indicated that the resident was moderately cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included heart failure. Review of clinical records revealed she was discharged from the facility on May 17, 2025. […]

• Actual harm, isolatedF600Apr 8, 2025

  Based on review of policies, investigative reports, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to follow a resident's care plan for assisting with Activities of Daily Living (ADL's) and preventing falls for one of three residents reviewed (Resident 1), resulting in a fall and fracture for the resident. Findings include: The facility's policy regarding resident abuse, dated September 27, 2024, revealed that all management and staff are responsible to ensure that every resident will be free from verbal, sexual, physical, or mental abuse, corporal punishment, involuntary seclusion, neglect, retaliation, humiliation or misappropriation of resident property. […]