Keysville Nursing Home & Rehab

In the surveyor’s words

From the most serious findings on record at Keysville Nursing Home & Rehab, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812May 22, 2022

  Base on observation, staff interview, and the facility policy titled Servicing Product Dispensers, the facility failed to maintain the cleanliness and sanitation of the ice machine. This had the potential to effect 61 residents receiving an oral diet. The facility census was 63. Findings include: Review of the facility policy titled Servicing Product Dispensers dated reviewed/revised 2/22 revealed: All product dispensers are to be maintained in a clean, hygienic serviceable manner. 2. Staff will ensure product dispensers are clean and fully operational. An observation and interview conducted on 5/20/22 at 7:15 a.m. revealed the ice machine in the kitchen had a dark black grime substance on the ice deflector in the back of the inside of the ice machine. […]

• No harm, potential for more than minimal, isolatedF640Jun 8, 2026

  Based on staff interviews and record review, the facility failed to transmit a Discharge Minimum Data Set (MDS) within 14 days after completion for one of 17 sampled residents (R) (R20). Findings include:Review of R20's clinical record revealed resident deceased on [DATE] at 5:50 AM.Review of the MDS listing for R20 revealed a Quarterly MDS on [DATE]. Further review of the current MDS listing revealed that there were no updates or modifications to the MDS since R20's death on [DATE].During an interview with the MDS Coordinator on [DATE] at 2:10 PM, she stated that she was responsible for updating the MDS when a resident is discharged or passed away. […]

• No harm, potential for more than minimal, isolatedF655Jun 8, 2026

  Based on staff interviews, record review, and facility policy review, the facility failed to develop and implement a baseline care plan within 48 hours of admission for one of 12 newly admitted residents (R) (R5) reviewed for baseline care planning. This deficient practice had the potential to delay communication of the resident's immediate care needs and interventions to staff responsible for providing care. Findings include: A review of the facility policy titled, Baseline Care Plan, last reviewed May 2026, facility policy, Baseline Care Plan, revealed that the facility would develop and implement a baseline care plan for each resident within 48 hours of admission. […]

• No harm, potential for more than minimal, isolatedF656Jun 8, 2026

  Based on staff interviews, record review, and review of the facility policy titled, Comprehensive Care Plans, the facility failed to develop a comprehensive care plan for two of 17 sampled residents (R) (R7 and R5) related to Foley catheter. The deficient practice had the potential for R7 and R5 to have needs and services go unmet. Findings include: A review of the facility policy, Comprehensive Care Plans, last revised May 2026, revealed under Policy Explanation and Compliance Guideline: 1. That the care planning process would include an assessment of the resident's strengths and needs. 2. The comprehensive plan would be developed within seven days after the comprehensive MDS (minimum data set) assessment. […]

• No harm, potential for more than minimal, isolatedF695Jun 8, 2026

  Based on observations, staff interviews, record review, and review of the facility policy titled Oxygen Administration, the facility failed to ensure oxygen delivered via nasal cannula was administered at the physician-prescribed flow rate for one of 12 residents (R) (R28) receiving oxygen therapy. This deficient practice had the potential to result in inadequate or excessive oxygen delivery, placing the resident at risk for adverse outcomes.Findings Include:Review of facility policy, Oxygen Administration (reviewed/revised May 2026), states that oxygen is administered under physician orders except in an emergency. […]