Redstone Highlands Health Care

jeopardy to resident health or safety

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.

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