Inspection Reports for
Keystone Commons

Incident reporting: The Residence filed 24 incident reports greater than 24 hours after the occurrence of the incident during the period reviewed (repeat finding).

Emergency call response: In the months of November 2022, July 2023 and February 2024, there were 300 e-call response times over the reasonable response time as required by the Residence policy (repeat finding).

Quality assurance program: Documentation was missing or incomplete for audits conducted in calendar years 2022 and 2023, including missing dates, responsible staff, follow-up actions, and outcomes (repeat finding).

Resident care plans: Four records were missing documentation of a Service Plan reassessment required within 30-days after the commencement of residency.

Resident records: The Residence did not consistently document information necessary during each 24-hour period for the continuity of care for Residents in the correspondence logs.

Staff training: Two records lacked documentation to support that Introductory Visits were consistently conducted by a nurse.

Memory care unit: Documentation to support the required Bi-annual Special Care Residence operations review was incomplete for the second quarter of 2022 and 2023 calendar years reviewed (repeat finding).

Memory care unit: Windows and doors in the common areas and resident rooms within Special Care Residences pose a risk of potential hazard related to the special characteristics of the population.