Inspection Reports for
Keystone Nursing Care Center
250 Fifth Street, Keystone, IA, 522499521
Back to Facility Profile15 Reports
Inspection Report — Sep 11, 2025
Annual Inspection CMS
Date: Sep 11, 2025
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Keystone Nursing Care Center Inc.
Findings
No health deficiencies were found during the inspection.
Inspection Report — May 8, 2025
Complaint Investigation State
Date: May 8, 2025
Visit Reason
A complaint investigation for complaint #127169-C and facility reported incident #127120-I was conducted from May 7, 2025 to May 8, 2025.
Complaint Details
Investigation was related to complaint #127169-C and facility reported incident #127120-I; the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance at the time of the survey.
Inspection Report — Feb 27, 2025
Re-Inspection State
Date: Feb 27, 2025
Visit Reason
A revisit of the survey ending February 6, 2025 was conducted on February 26, 2025 to February 27, 2025 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective February 20, 2025.
Inspection Report — Feb 6, 2025
Complaint Investigation State
Date: Feb 6, 2025
Visit Reason
The inspection was conducted as an investigation of complaint #125885-A and facility reported incident #125864-M, which involved a resident fall and injury.
Complaint Details
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.
Findings
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.
Violations (1)
Failure to properly transfer a resident using a mechanical lift as directed in the care plan, resulting in a fall and fractured femur.
Report Facts
Complaint number: 125885
Incident number: 125864
Resident age: 97
BIMS score: 10
Vital signs: Temperature 97.9 F, pulse 102 bpm, respirations 20 per minute, blood pressure 148/84, oxygen saturation 94%
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Bruys | RN BSN Admin | Signed the plan of correction letter dated 2/20/2025 |
| Staff A | Employee who transferred the resident improperly, causing the fall | |
| Staff B | LPN | Reported details of the fall and resident condition |
| Staff D | Assisted with resident transfer and involved in incident investigation | |
| Staff C | CNA | Witnessed and reported on resident transfer and fall incident |
| Director of Nursing | DON | Conducted internal investigation and interviewed staff |
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding incident and staff actions |
Inspection Report — Sep 19, 2024
Annual Inspection CMS
Date: Sep 19, 2024
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements for Keystone Nursing Care Center Inc.
Findings
No health deficiencies were found during the inspection.
Inspection Report — Aug 2, 2024
Complaint Investigation State
Date: Aug 2, 2024
Visit Reason
A complaint investigation was conducted for complaint #122484-C and a facility reported incident #116417-I.
Complaint Details
Complaint #122484-C and facility reported incident #116417-I were investigated and found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Inspection Report — Jul 10, 2023
Plan of Correction State
Date: Jul 10, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance status following a survey.
Findings
The facility was certified in compliance based on acceptance of a credible allegation of compliance and plan of correction effective July 10, 2023. No specific deficiencies or severity levels are detailed in the report.
Inspection Report — Jun 22, 2023
Complaint Investigation CMS
Date: Jun 22, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to notify the physician about elevated blood sugars for Resident #205 and failure to document non-pharmacological interventions prior to administering PRN anxiolytics for Resident #26.
Complaint Details
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.
Findings
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.
Violations (2)
Failed to notify the physician for elevated blood sugars over 400 mg/dL for Resident #205.
Failed to document non-pharmacological interventions prior to administration of PRN anxiolytics for Resident #26.
Report Facts
Blood sugar readings: 486
Blood sugar readings: 409
Blood sugar readings: 414
Blood sugar readings: 402
Blood sugar readings: 416
Blood sugar readings: 418
PRN anxiolytic administrations: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Interviewed regarding blood sugar notification policy and PRN anxiolytic documentation |
| Staff B | Licensed Practical Nurse (LPN) | Interviewed regarding blood sugar notification policy |
| Staff C | Licensed Practical Nurse (LPN) | Interviewed regarding blood sugar notification policy and Resident #205 elevated blood sugars |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding blood sugar notification policy and PRN anxiolytic documentation |
Inspection Report — Jun 22, 2023
Annual Inspection State
Date: Jun 22, 2023
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of Complaint #113311-C.
Complaint Details
Complaint #113311-C was substantiated.
Findings
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.
Violations (2)
Facility failed to notify the Physician for elevated blood sugars for Resident #205.
Facility failed to document non-pharmacological interventions attempted prior to administration of PRN anxiolytics for Resident #26.
Report Facts
Blood sugar readings: 500
Blood sugar readings: 50
MDS Brief Interview for Mental Status score: 14
MDS Brief Interview for Mental Status score: 7
PRN anxiolytic medication dose: 0.5
Medication administration times: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Bruns | RN BSN Admin | Signed the plan of correction |
| Licensed Practical Nurse (LPN) Staff A | Interviewed regarding PRN anxiolytic interventions | |
| Licensed Practical Nurse (LPN) Staff B | Interviewed regarding blood sugar policy and physician notification | |
| Licensed Practical Nurse (LPN) Staff C | Interviewed regarding blood sugar policy and physician notification | |
| Director of Nursing (DON) | Interviewed regarding blood sugar policy and PRN anxiolytic administration |
Inspection Report — Apr 8, 2022
Plan of Correction State
Date: Apr 8, 2022
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction effective April 8, 2022.
Inspection Report — Apr 7, 2022
Annual Inspection State
Date: Apr 7, 2022
Visit Reason
The inspection was conducted as the facility's Annual Recertification Survey from April 4, 2022 to April 7, 2022.
Findings
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.
Violations (1)
Facility failed to ensure expired food items were served to residents and failed to label and date food items when opened to reduce contamination risk.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Supervisor | Interviewed during kitchen tour regarding food labeling and expiration | |
| Facility Dietician | Present during kitchen tour revealing food labeling issues |
Inspection Report — Jan 7, 2021
Annual Inspection State
Date: Jan 7, 2021
Visit Reason
The inspection was conducted as a recertification survey from January 4, 2021 to January 7, 2021, including investigation of complaint #91457.
Complaint Details
Complaint #91457 investigation was unsubstantiated.
Findings
The facility was found in substantial compliance at the time of the recertification survey. The complaint investigation was unsubstantiated.
Inspection Report — Dec 8, 2020
Abbreviated Survey State
Date: Dec 8, 2020
Visit Reason
A Focused COVID-19 Infection Control Survey was conducted on 12/7-8/2020 by the Department of Inspections and Appeals to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report — Nov 18, 2020
Routine State
Date: Nov 18, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 11-17-20 and 11-18-20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report — Jun 24, 2020
Abbreviated Survey State
Date: Jun 24, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 6/24/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
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