Pruitthealth - Lakehaven, LLC

Based on observations, interviews, and review of policies titled, Cleaning Procedures: Kitchen Area and Cleaning Schedule Policy, the facility failed to ensure that the ice machine was clean and sanitized. The deficient practice had the potential to affect 64 residents of 70 receiving an oral diet.Findings Include:Review of the facility policy titled, Cleaning Procedures: Kitchen Area, (revised 4/14/2016) revealed Under Policy Statement: It is the policy of (Facility Name) to maintain a clean and sanitary environment to prepare patient/resident meals. Review of the facility policy titled, Cleaning Schedule Policy revised date of 9/29/2022 revealed under Policy Statement: It is the policy of (Facility Name) that the Dietary Manager prepares a list of all cleaning tasks and posts them in the Dietary Department. It is the Dietary Manager's responsibility to develop and enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks to promote a sanitary environment. Observation on 8/4/2025 at 11:06 am revealed the inside of the ice machine where the door opens,…

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, staff interviews, record review, and review of the facility's policy titled, Care Plans, the facility failed to ensure dialysis care plan for one of eight residents (R) (R93) was developed to meet the residents' care needs. Specifically, the facility failed to ensure R93 care plan indicated residents' repeated refusal of dialysis treatments. Findings Include:Review of the facility's policy titled, Care Plan, dated 7/27/2023 under the Policy Statement revealed, It is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) Manual and the patient/resident choice. Under the section titled, Procedure: New admission Baseline Plan of Care revealed, 2. The baseline care plan will be updated to reflect changes to approaches,…

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, staff interviews, and review of the facility policy titled, Foodborne Illnesses, the facility failed to ensure the Main Kitchen was maintained in a clean and sanitary condition. Specifically, the facility failed to ensure the main oven was clean and free from debris, the ice machine was clean and free of debris, and that the cooler racks in the walk-in cooler were clean and free of built-up grime and debris. The facility also failed to ensure the steam table was clean and free from food splatter and built-up grime and debris. The deficient practice had the potential to affect 75 of 78 residents receiving an oral diet. Findings: Review of the facility policy titled, Foodborne Illnesses dated 1/8/2021 revealed under Policy Statement: It is the policy of PruittHealth that the Dietary Manager be ServSafe certified in accordance with local, state, and federal regulations. This ensures the proper preparation and serving of foods under safe and sanitary conditions to prevent the spread of bacteria which may lead to food borne illnesses. Under procedure number 3. It…

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, resident and staff interviews, record review, and review of the facility policy titled, Self-Administration of Medications by Patients/Residents, the facility failed to ensure two of 34 residents (R) (R23 and R30) did not have unsecured, unauthorized medications stored at the bedside. This deficient practice had the potential to allow unauthorized access of medications to other residents and visitors in the facility. Finding include: Review of the facility policy titled, Self-Administration of Medications by Patients/Residents revised 1/28/2020 under Policy Statement: Each patient /resident who desires to self-administer medication is permitted to do so if the healthcare center's Licensed Nurse and physician have determined that the practice would be safe for the patient/resident and other patients/residents of healthcare center. 3). If the Licensed nurse determines the patient/resident or family member to be capable of self -administration of medications, the attending physician must…

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, staff interviews, record review, and review of the facility policy titled, Care Plans, the facility failed to implement the care plan for two of ten Residents (R) (R47, and R48) receiving oxygen therapy. Specifically, the facility failed to ensure the care plans for R47 and 48 were followed in reference to the oxygen flow rate for each resident. Findings include: Review of the facility policy titled, Care Plans revised 7/27/2023 Under admission Comprehensive Plan of Care number 4. The care plan will contain four main components: Problem, Goal, Approaches and Role or Accountability. The care plan approach serves as instruction for the patient/resident's care and provides continuity of care by all partners. Record review for R47 revealed resident was admitted to the facility with diagnoses of but not limited to Chronic Obstructive pulmonary disease (COPD), dependence on supplemental oxygen, and acute and chronic respiratory failure with hypoxia. Review of the plan of care revealed a problem at risk of respiratory distress r/t (related to) shortness of breath,…

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, staff and resident interviews, record review, and review of the facility policy titled, Oxygen Administration, the facility failed to ensure one of four residents (R) R30 had a physicians order for continuous oxygen use to include the frequency of use and flow rate, the facility also failed to ensure R47 and R48 were administered oxygen therapy in accordance with physician order. Specifically, the facility failed to ensure R30 had a written physicians order for use of continuous oxygen, and also failed to ensure R47 and R48 were receiving oxygen at the rate as prescribed by the physician. Findings include: Review of the facility policy titled, Oxygen Administration revised 8/2/2023 revealed under Policy Statement: It is the policy of [NAME] Health Hospice and Healthcare Centers /Veteran Homes to provide oxygen safely and accurately to appropriate patients/residents. Record review for R30 revealed the following diagnoses but not limited to dependence on supplemental oxygen, Chronic…

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 review, and review of the facility policy titled, Skilled Nursing Facility (SNF) Outpatient Dialysis Services Agreement the facility failed to have ongoing communication and collaboration with the dialysis center for one of five Residents (R) (R73) reviewed for dialysis. This failure had the potential to affect all five residents receiving dialysis services. Findings include: Review of the facility's policy titled Skilled Nursing Facility (SNF) Outpatient Dialysis Services Agreement dated 1/16/2018 under Interchange of information: the nursing facility shall provide for the interchange of information useful or necessary for the care of End Stage Renal Disease (ESRD) residents, including a registered nurse as a contact person at the nursing facility whose responsibilities include oversight of provision of services to the ESRD residents. D. Mutual Obligations 1. Collaboration of Care. Both parties shall ensure that there is documented evidence of collaboration of care and communication between the Nursing Facility and ESRD Dialysis Unit. Review of the…

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 interviews, and record review, the facility failed to provide and complete accurate medical records documenting Activities of Daily Living (ADL) care for one of five residents (R) R64. The deficient practice had the potential to inaccurately depict the care provided for R64 during ADL care. Findings include: Resident 64 was admitted to the facility with diagnoses that included but no limited to dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Displaced comminuted fracture of shaft of humerus, right arm, subsequent encounter for fracture with routine healing, Stiffness of joint. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] documented R64 had a Brief Interview for Mental Status (BIMS) of 10 which indicated moderate cognitive impairment. Further review revealed R64 is dependent for Toileting hygiene/Shower/bathe and Upper/lower body dressing. Review of R64 shower log from November 1, 2023 to March 20, 2023, revealed R64 missed the…

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, resident and staff interviews, and record review, the facility failed to store oxygen therapy equipment in a sanitary manner for three of four residents (R30, R47, and R48) receiving oxygen therapy via medical devices Continuous Positive Airway Pressure (CPAP) and Bilevel positive airway pressure (BiPap). The deficient practice increased the probability for R30, R47, and R48 to contract a respiratory infection by not ensuring equipment was properly stored. Findings: Policy requested but not provided by facility. Record review for R30 revealed the following diagnoses but not limited to dependence on supplemental oxygen, Chronic respiratory failure, and shortness of breath. Care Plan dated 6/26/2023 revealed under Problem: resident requires oxygen therapy, CPAP related to (r/t) shortness of breath lying flat and on exertion, morbid obesity, heart failure. Goal: resident will not exhibit signs of hypoxia. Approach: CPAP as ordered. Review of the Quarterly Minimum Data Set (MDS) assessment…

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, staff interviews, and review of policy titled Diagnostic and Laboratory Services the facility failed to timely follow a Nurse Practitioner's (NP) telephone order to collect a urine specimen to send to the laboratory for a urinalysis for one resident (R)130) in a sample of 24 residents reviewed. Findings include: Review of the facility's policy titled Diagnostic and Laboratory Services dated 10/24/18, revealed .The licensed nurse will date and sign that the specimen was obtained OR note that it was not obtained in the Daily Lab Draw Form .If the lab specimen is unable to be obtained a second time, the provider will be notified and a new order obtained .The licensed nurse will document the above in the clinical record and on the 24 hour report. Review of R130's Electronic Medical Record (EMR) under the Face sheet tab revealed R130 was admitted on [DATE] and discharged home on [DATE]. R130 had diagnosis which included history of Urinary Tract Infections (UTI). Review of R130's quarterly…

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.