Keystone Post-Acute

In the surveyor’s words

From the most serious findings on record at Keystone Post-Acute, in the surveyor’s own words.

• Immediate jeopardy, patternF559Dec 20, 2022

  Based on observation, interview and record review, the facility failed to ensure residents' right to receive written notice, including the reason for the change, before the resident's room or roommate was changed, was not supported for 16 of 26 sampled residents (Resident 1,2,3,4,5,7,8,9,11,12,13,14,15,16,18,22) when Resident 1, Resident 2, Resident 3, Resident, 4, Resident 5, Resident 7, Resident 8, Resident 9, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 16, Resident 18 and Resident 22 were moved from their assigned room to another room in the facility without first receiving written notice. […]

• Actual harm, isolatedF689Nov 15, 2023

  Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 7) was free from accidents, when Resident 7, who was identified as being at-risk for falls with a history of multiple falls in the facility, fell and was injured when left unattended in her unlocked wheelchair on 8/31/23. This failure resulted in Resident 7 being sent to the general acute care hospital (GACH) for evaluation. Resident 7 was diagnosed with an odontoid fracture (break of the second bone in the neck) and was hospitalized from 8/31/23 to 9/8/23. […]

• Actual harm, isolatedF656Aug 5, 2022

  Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to prevent falls, for one of five sampled residents (Resident 27), when Resident 27 had known behavior of getting up unassisted from bed, was assessed as being a high fall risk, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in Resident 27 getting out of bed unassisted on 4/11/22. Resident 27 fell and sustained a displaced right intertrochanteric fracture (broken hip bone that have moved out of their normal position) and right anterolateral (in front and to the side) second, third, fourth, fifth, sixth and seventh rib fractures and experienced pain. […]

• Actual harm, isolatedF689Aug 5, 2022

  Based on observation, interview and record review, the facility failed to ensure residents were free from accidents for one of five sampled residents (Resident 45), when Resident 45 was identified as being at risk for falls with a history of multiple falls in the facility and the care plan intervention to place the bed in the low position was not implemented on 12/27/21. This failure resulted in Resident 45 experiencing an unwitnessed fall from the bed on 12/27/21 onto the floor. After the fall, Resident 45 experienced left side pain and was sent to the general acute care hospital (GACH) for evaluation. Resident 45 was diagnosed with a left femur fracture (broken thighbone) and required surgical repair and was hospitalized from 12/27/21 to 1/4/22 (eight days). […]

• Actual harm, isolatedF689Sep 3, 2021

  Based on observation, interview and record review, the facility failed to ensure residents' environment remained free of accident hazards (potential to cause injury or illness) to prevent accidents for one of three sampled residents (Resident 1), when an extra walker (an assistive device used for support and stability when walking) was left at the end of Resident 1's bed. This failure resulted in Resident 1 tripping over an extra walker on 6/23/21, causing Resident 1 to fall onto the floor, which resulted in a left patella (kneecap) fracture (break in the bone). […]