Inspection Reports for
Keystone Nursing Care Center

The investigation was triggered by a complaint regarding improper transfer of Resident #1. The complaint was substantiated as Staff A transferred the resident without the mechanical lift and one staff member, contrary to the Care Plan, resulting in a fall and injury. Staff A admitted fault and was terminated.

The facility failed to properly transfer Resident #1 using a mechanical lift and two staff as directed, resulting in a fall with a fractured femur and other injuries. Staff A transferred the resident alone without the mechanical lift, causing the resident to fall and sustain serious injuries. Staff A was suspended and then terminated. The resident later died after being discharged to hospice care.

The visit was complaint-related, investigating complaint #125885-A and facility reported incident #125864-M. The complaint was substantiated as the facility failed to follow the care plan for resident transfers, leading to injury.

The facility failed to properly transfer a resident using a mechanical lift as required by the care plan, resulting in a fall with a fractured femur. Multiple progress notes and interviews documented the incident, the resident's injuries, and staff actions. The facility suspended the involved staff and initiated corrective actions.

The complaint investigation found that the facility did not notify the physician for blood sugar readings over 400 mg/dL for Resident #205 on multiple dates in June 2023, despite policy requiring notification. Staff interviews showed varied understanding of notification requirements. The Director of Nursing confirmed expectation to notify the physician for blood sugars over 400 mg/dL unless otherwise ordered.

The facility failed to notify the physician for elevated blood sugars above 400 mg/dL for Resident #205 on multiple occasions despite documented high blood sugar readings. Staff interviews revealed inconsistent understanding of notification policies, and the facility policy required immediate notification for fasting blood sugars greater than 400 mg/dL.

The visit was complaint-related focusing on failure to notify physician for elevated blood sugars and failure to document non-pharmacological interventions prior to PRN anxiolytic administration. The deficiencies were substantiated with evidence from clinical record reviews and staff interviews.

The facility failed to notify the physician for elevated blood sugars over 400 mg/dL for Resident #205 despite multiple documented high readings without physician notification. Additionally, the facility failed to document non-pharmacological interventions attempted prior to administering PRN anxiolytics for Resident #26. Both deficiencies were found to pose minimal harm and affected a few residents.

Complaint #113311-C was substantiated.

The facility was found deficient in quality of care related to failure to notify the physician for elevated blood sugars for one resident and failure to document non-pharmacological interventions prior to administration of PRN anxiolytics for another resident. The complaint was substantiated.

The facility failed to ensure expired food items were properly labeled and dated to reduce the risk of contamination and food-borne illness. Multiple food items in the kitchen were found unlabeled or past their best-by dates.