Pruitthealth - Lakehaven, LLC

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on record review, interviews, and review of the facility policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to protect the resident's(s') right to be free from deprivation of services by Licensed Practical Nurse (LPN) QQ. Specifically, the facility failed to ensure one resident (R) (R1) of four sampled residents, was assessed when experiencing a decline in respiratory status as evidenced by becoming hypoxic and cyanotic. On 7/1/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility Administrator and the Director of Health Services (DHS) were informed of Immediate Jeopardy on 7/1/2024, at 10:22 am. [...]

Inspectors wroteBased on staff interviews, record review, and the facility policy titled Care Plans, the facility failed to develop a person-centered baseline care plan for one resident (R) (R1) of three residents reviewed for care and treatment of resident with chronic respiratory complications. This deficient practice had the potential to have an adverse effect for the resident. On 7/1/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy (IJ) on 7/1/2024 at 10:22 am. The noncompliance related to the Immediate Jeopardy was identified to have existed on 6/2/2024. At the time of exit on 7/3/2024, the Immediate Jeopardy remained ongoing.

Inspectors wroteBased on record review and interviews, review of the facility's tools Using SBAR Communication, the facility failed to ensure one resident (R) (R1) of four sampled residents received necessary respiratory care. Nursing staff did not assess resident during an acute change in condition, did not notify the physician, and attempted to cancel a 911 call which R1 initiated. In addition, facility's nursing staff did not document anything in R1's clinical record related to the change in condition. On July 1, 2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy (IJ) on July 1, 2024, at 10:22 am. [...]

Inspectors wroteBased on interviews, record reviews, and review of the job summaries for the Administrator and Director of Health Service (DHS), the facility Administration failed to effectively oversee an abuse prevention program to promote, foster, and maintain an abuse-free environment, failed to provide monitoring and oversight for respiratory care, and failed to develop a care plan to address chronic respiratory conditions which were present on admission to the facility for one resident (R) R1. The facility census was 75. On 7/1/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy (IJ) on 7/1/2024 at 10:22 p.m. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.