Keystone Nursing Care Center INC

In the surveyor’s words

From the most serious findings on record at Keystone Nursing Care Center INC, in the surveyor’s own words.

• Actual harm, isolatedF677Feb 6, 2025

  Based on observations, interviews, and record review, the facility failed to properly transfer 1 of 4 residents reviewed for mechanical lift transfers (Resident #1). Staff transferred Resident #1 into the shower without the use of a mechanical lift and a second staff person assisting directly with the transfer as directed in her Care Plan. This resulted in a fall with a fractured femur. The facility reported a census of 39 residents. Findings include: A Minimum Data Set, dated dated dated [DATE], documented that Resident #1's diagnoses included osteoarthritis, right knee pain, weakness, and unspecified hearing loss. A Brief Interview for Mental Status (BIMS) revealed a score of 10 out of 15, which indicated the resident had moderate cognitive impairment. […]

• No harm, potential for more than minimal, patternF812Apr 7, 2022

  Based on observation, staff interview and policy review, the facility failed to ensure expired food items were served to residents and failed to label and date food items when opened to reduce the risk of contamination and food-borne illness. The facility reported a census of 40 residents. Findings Include: On [DATE] at 9:20 AM during the initial tour of the facility kitchen with the Dietary Supervisor and facility Dietician, revealed the following: a. A clear plastic bin containing small candy M&M's in an open bag not labeled or dated when opened or a best by date. b. A clear plastic bin containing small white chocolate chips in an open bag not labeled or dated when opened or a best by date. c. A partial pasta bag not dated when opened. d. […]

• No harm, potential for more than minimal, isolatedF684Jun 22, 2023

  Based on clinical record review, resident and staff interviews and facility policy review, the facility failed to notify the Physician for elevated blood sugars for 1 of 2 residents reviewed for insulin usage (Resident #205). The facility reported a census of 48. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #205 scored 14 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognitively intact. The MDS identified medical diagnosis of diabetes mellitus. The MDS revealed the resident received insulin injections 7 out 7 days. The Care Plan entry dated 12/17/21 revealed a focus problem of diabetes mellitus. […]

• No harm, potential for more than minimal, isolatedF758Jun 22, 2023

  Based on clinical record review and staff interview, the facility failed to document non-pharmacological interventions attempted prior to the administration of as needed (PRN) anxiolytics (medications used to treat anxiety) for 1 of 2 residents reviewed for prn anxiolytic use(Resident #26). The facility reported a census of 48 residents. Findings Include: The Minimum Data Set (MDS) Assessment tool, dated 4/20/23, listed diagnoses for Resident #26 which included Parkinson's disease, mild cognitive impairment, and adult failure to thrive. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 7 out of 15, indicating severely impaired cognition. […]