Keystone Pointe Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Keystone Pointe Health and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Mar 2, 2021

  Based on observations, interviews, and record reviews, the facility failed to have an effective Infection Prevention and Control Program (IPCP) to prevent the potential transmission of COVID-19 within the facility. The facility failed to ensure all staff and visitors were screened and that the absence of signs/symptoms of COVID-19 were documented. Additionally, the facility failed to ensure all staff followed proper Personal Protective Equipment (PPE) usage and completed proper hand hygiene for five of seven sampled residents (Resident (R) 1, R2, R3, R4, and R5). Both the facility's failures had the potential to affect all 91 residents who resided in the facility at the time of the survey. Findings include: 1. […]

• No harm, potential for more than minimal, isolatedF558Sep 13, 2022

  Based on observations, medical record review, and staff interviews, the facility failed to ensure the residents had access to a call light. This affected one (Resident #57) of four residents reviewed for call lights. The facility census was 111. Findings include: Review of Resident #57's medical record revealed an admitted to the facility occurred on 07/29/20. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #57's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 eats independently. Observation and interview with Resident #57 on 09/12/22 at 7:54 A.M. revealed Resident #57 was verbal and able to identify her name, location, date of birth and children's names. Resident #57 was also observed with some confusion. […]

• No harm, potential for more than minimal, isolatedF807Sep 13, 2022

  Based on observations, medical record review, and staff interviews, the facility failed to ensure a resident received the correct thickened consistency of fluids per physician orders. This affected one (Resident #57) of four residents reviewed for diet orders. The facility identified four residents who receive thickened liquids. The facility census was 111. Findings include: Review of Resident #57's medical record revealed an admission to the facility occurred on 07/29/20. Diagnoses included stroke, [CONDITION(S)], anxiety, dysphasia and high blood pressure. Review of Resident #57's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 eats independently. […]

• No harm, potential for more than minimal, isolatedF755Feb 11, 2022

  Based on observations, staff and resident interview, review of the pharmacy narcotic record and policy review the facility failed to ensure nursing staff followed medication administration procedures. This affected three residents (#10, #59 and #81) of seven reviewed for medication administration on the East 100/200 hallway. The facility census was 115. Findings include: 1. Observation and interview with Licensed Practical Nurse (LPN) #220 on 02/11/22 at 5:31 A.M., LPN #220 confirmed she usually started her medication pass at 4:00 A.M. LPN#220 confirmed she knows she should not give medications more than an hour earlier than ordered; however she does start early. Observation with LPN #220 on 02/11/22 at 5:41 A.M. administering medications for Resident #81. […]

• No harm, potential for more than minimal, isolatedF760Feb 11, 2022

  Based on medical record review, observation, resident and staff interviews and review of the pharmacy narcotic count record the failed to prevent a significant medication error for one resident (#59) of seven residents observed for medication administration. The facility census was 115. Findings include: Review of the medical record revealed Resident #59 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #59 had intact cognition. Resident #59 was on palliative care services for pain management. Observation of medication administration completed with Licensed practical Nurse (LPN #230) on 02/11/22 at 7:50 A.M. […]