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Deficiency Records for Keystone Post-Acute
A list of the most recent deficiencies for Keystone Post-Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Keystone Post-Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-08-21 | 2024-09-13 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-13 | 2024-07-05 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-04-26 | 2024-05-31 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-04-26 | 2024-05-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-26 | 2024-05-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-04-26 | 2024-05-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-04-26 | 2024-05-31 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-04-26 | 2024-05-31 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-04-26 | 2024-05-31 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-04-26 | 2024-05-31 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-04-26 | 2024-05-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-26 | 2024-05-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-04-26 | 2024-05-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-26 | 2024-05-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-04-26 | 2024-05-31 | N |
| Keep all essential equipment working safely. | Health | 2024-04-26 | 2024-05-31 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2024-04-26 | 2024-05-31 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2024-04-26 | 2024-05-31 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-04-22 | 2024-05-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-04-22 | 2024-05-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-04-22 | 2024-05-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-04-22 | 2024-05-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-04-22 | 2024-05-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-04-22 | 2024-05-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-15 | 2023-12-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-17 | 2023-11-02 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-05-25 | 2023-06-30 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-12-20 | 2023-01-27 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-12-20 | 2023-01-27 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-12-20 | 2023-01-27 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-08-05 | 2022-11-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-05 | 2022-11-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-05 | 2022-08-30 | N |
| Provide activities to meet all resident's needs. | Health | 2022-08-05 | 2022-08-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-05 | 2022-08-30 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-08-05 | 2022-08-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-05 | 2022-08-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-05 | 2022-08-30 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-08-05 | 2022-08-30 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-08-05 | 2022-08-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-05 | 2022-08-30 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-08-09 | 2022-08-26 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-08-09 | 2022-08-26 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-08-09 | 2022-08-26 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-08-09 | 2022-08-26 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-08-09 | 2022-08-26 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-08-09 | 2022-08-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-09 | 2022-08-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-08-09 | 2022-08-26 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-08-09 | 2022-08-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-09 | 2022-08-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-09 | 2022-08-26 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-08-09 | 2022-08-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-09 | 2022-08-26 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-08-09 | 2022-08-26 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-09 | 2022-08-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-09 | 2022-08-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-09 | 2022-08-26 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-08-09 | 2022-08-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-05 | 2022-02-11 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-01-05 | 2022-02-11 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-06-13 | 2019-07-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-13 | 2019-07-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-13 | 2019-07-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-13 | 2019-07-10 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2019-05-03 | 2019-05-31 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-05-03 | 2019-05-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-03 | 2019-05-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-03 | 2019-05-31 | N |
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