PruittHealth - Lakeside, LLC

Based on observations, staff interviews, and a review of the facility's policy titled Labeling, Dating, and Storage, the facility failed to ensure food items in the walk-in refrigerator, freezer, emergency water/food supply, and dry storage were properly dated and expired foods were disposed of. The deficient practices had the potential to place 53 of 55 residents(R) who receive food from the kitchen at risk of contracting a foodborne illness.Findings Include:Review of the facility's policy titled Label, Dating, and Storage, reviewed and dated 11/11/2022, documented in Procedure 1: Food and beverage items will have an identifying label as well as a received date and opened date, as applicable; for items prepared onsite, a use by date will also be indicated.During the initial tour on 04/14/2026 at 8:42 AM, with the Assistant Kitchen Manager (AKM) and Kitchen Manager(KM), it was revealed the freezer contained opened items such as a bag of squash, a box of red velvet layer cake, and a bag of sliced salami, boxes of ground beef, vanilla ice cream, and orange juice were open with no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure the need for a Level II Preadmission Screening/Resident Review (PASARR) for evaluation and determination for specialized services were offered to meet resident needs for one of 10 sampled residents (R) (R9) for PASARR Level II.Findings include:Review of Electronic Health Record (EHR) revealed R9 had diagnoses of but not limited to unspecified intellectual disabilities, schizoaffective disorder, degenerative disease of nervous system. Further review revealed R9 had a diagnosis of schizoaffective disorder upon admission on [DATE].Review of the Annual Minimum Data Set (MDS) dated [DATE] for R9 revealed she was admitted to the facility on [DATE]. Section A revealed R9 had not been evaluated for Level II PASARR.Review of Care Plan dated 04/15/2026 revealed R9 Problem: Resident is resistive of care from staff. Resident may swing at staff during care provided. Approach: Explain the care staff wants to provide to the resident. Behavior monitoring…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to ensure the timely submission of the Minimum Data Set (MDS) assessment for one of five residents (R) (R49). The deficient practice had the potential to increase the probability for R49 not to receive care according to their care needs. Findings include: Record review for R49 revealed resident was admitted to the facility with the diagnoses of but not limited to chronic kidney disease stage 5, type 2 diabetes, chronic obstructive pulmonary disease, right upper quadrant abdominal mass, essential hypertension, syncope and collapse, hyperlipidemia, bradycardia, and generalized anxiety disorder. Resident medication review revealed a physicians order for the following, atorvastatin 40 mg (milligram), Breo Ellipta 100-25, buspirone 10 mg, clopidogrel 75 mg, gabapentin 300 mg, hydroxyzine 25 mg, pantoprazole 20 mg, paricalcitol 1 mcg (microgram), and paroxetine Hcl (hydrochloride) 40 mg. Review of R49's Quarterly Minimum Data Set (MDS) assessments…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interviews, the facility failed to ensure that Minimum Data Set (MDS) assessments was accurate for one resident (R) (R15) related to inaccurate coding of the preadmission screening and resident review (PASARR) level II. The sample size was 27. Findings include: A review of the Minimum Data Set (MDS) OBRA (Omnibus Budget Reconciliation Act) Annual Assessment, Section A-Identification A, dated 12/19/24, revealed R15 was not assessed for PASARR level II. A review of the medical record revealed R15 had a PASARR level II assessment, with a start date of 8/25/23 and end date of 12/31/2299. During an interview with the MDS Coordinator on 3/1/2025 at 3:25 pm, she acknowledged the MDS OBRA Annual Assessment, Section A-Identification Information, dated 12/19/24, indicated R15 had not been screened for a PASARR II. The MDS Coordinator confirmed that R15 was issued a PASARR II on 8/5/2023, and the MDS was not accurately coded. The MDS Coordinator said the Social Worker (SW) put the information in section A, but she said it was the MDS Coordinator's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interviews, record reviews, and a review of the facility policy titled, Legionella Water Management, the facility failed to develop an updated water management program plan for the prevention of Legionella for 52 of 52 residents in the building. The deficient practice had the potential to promote growth of Legionella and other opportunistic waterborne pathogens in the building water systems. Findings included: A review of the facility policy titled, Legionella Water Management, revised 2017, revealed 3. The purposes of water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. 4. The water management program used by our facility is based on the Centers for Disease Control and Prevention and ASHRAE recommendations for developing water management program. e. Specific measures used to control the introduction of and/or spread of legionella (e.g., temperature, disinfectants); f. The control limits or parameters that are acceptable and that are monitored; g. A diagram of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews the facility failed to ensure that it was maintained in a clean, comfortable, and homelike environment in four of 16 resident rooms (A111, A112, A113, and A115) on A hall and two of 16 resident rooms (B202 and B204) on B hall (two of three halls) that included dust and grime buildup on packaged terminal air conditioners (PTAC) vents and rooms A109/A111 and A110/A112 shared bathroom air vents with dust buildup. The facility census was 50. Findings revealed: The facility does not have a maintenance or housekeeping policy. Observations made during initial rounds on 11/03/2023 between 8:00 AM and10:00 AM revealed: Room A9/A11 and A10/A12 shared bathroom vent to have dust buildup. Rooms A11, A12, A13, A15, B2 and B4 PTAC units had dirt and dust buildup on the vents and front grate area. Observations made during initial rounds on 11/04/2023 at 9:00 AM revealed: Room A9/A11 and A10/A12 shared bathroom vent to have dust buildup. Rooms A11, A12, A13, A15, B2 and B4 PTAC units had dirt and dust buildup on the vents and front grate area. Interview and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interviews, staff interviews, and the review of the facility policy titled, Resident Trust Policy and a document titled Patient Trust Fund Authorization/Agreement the facility failed to provide resident trust fund account quarterly statements for three of four resident (R) (R#24, R#30, and R#39) reviewed. Forty-four (44) resident trust fund accounts are managed by the facility. Findings: Review of the undated policy titled, Resident Trust Policy revealed: Upon written authorization of a resident, Eastview Nursing Center must safeguard, manage, and account for the personal funds of the resident deposited in their account. 6. The resident shall have reasonable access, upon request, to a record of all transactions made to his/her account. Quarterly statements will be provided in writing to the resident or to the resident's responsible party. Review of the document titled, Patient Trust Fund Authorization/Agreement updated 5/19/2018 indicated: I acknowledge that I have been advised of my rights to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interview, and the review of the facility policy titled, Restorative Nursing Services, the facility failed to ensure one (Resident (R) 8 reviewed for range of motion (ROM) received a splint/brace as needed to address her limited range of motion in her right hand. The deficient practice had the potential for further reduction of ROM. The sample size was 19 residents. Findings include: Review of the facility policy titled, Restorative Nursing Services revised July 2017 revealed residents will receive restorative nursing care as needed to help promote optimal safety and independence. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services. Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and review of facility documents titled, Safety Data Sheets and Material Safety Data Sheets, the facility failed to store chemicals so that they were inaccessible to residents and visitors in one unoccupied resident room under renovation, on one of three halls. The facility census was 52. Findings include: Review of the Safety Data Sheet for ARDEX Feather Finish dated December 13,2020 revealed under Section 11- Toxicological Information: Routes of expose skin and eyes (yes), ingestion (yes). Skin corrosion or irritation causes skin irritation. Prolonged exposure to wet product may cause skin burns. Serious eye damage/eye irritation: Causes eye burns. May cause blindness. Specific Target Organ Toxicity, Single exposure: May cause respiratory irritation. Review of the Material Safety Data Sheet issue date August 1, 2013, revealed under Section 2- Hazards Identification: Hazard Statements: This product may cause slight irritation to the eye. May cause slight irritation to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews, and review of the facility policy titled, Prevention of Infection Oxygen Use, the facility failed to provide respiratory care consistent with professional standards of practice for one of four residents (R) (R17) receiving oxygen therapy related to ensuring oxygen filter were cleaned and oxygen nasal cannula were routinely changed. This deficient practice had the potential to cause respiratory associated infections and or illnesses. Findings include: Review of facility's undated policy titled, Prevention of Infection Oxygen Use under; Infection control Considerations Related to Oxygen Administration - 1. Obtain equipment (i.e., oxygen tubing, and prefilled humidifier). 2. [NAME] bottle with date and initials upon opening and discard when empty. 3. Check water level of any pre-filled reservoir. 4. Change pre-filled humidifier when empty. 5. Change the oxygen cannula and tubing every seven (7) days, or as needed. 6. Keep the oxygen cannula and tubing used PRN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.