Pruitthealth - Fleming Island

In the surveyor’s words

From the most serious findings on record at Pruitthealth - Fleming Island, in the surveyor’s own words.

• Immediate jeopardy, isolatedF578Jun 13, 2025

  Based on staff interviews, record review, and the facility's policy and procedure titled Advance Directives, the facility failed to act in accordance with Resident #1's Advance Directives and Full Code status (the desire to be resuscitated in the event of cardiac/respiratory arrest) after finding him unresponsive with no respirations. This affected one (Resident #1) of three residents reviewed for Advance Directives. The facility's failure to honor Resident #1's Advance Directives deprived him of potentially lifesaving measures. Resident #1 was not revived and expired in the facility. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 1:48 PM on [DATE]. […]

• Immediate jeopardy, isolatedF678Jun 13, 2025

  Based on staff interviews, record review, and a review of the facility's policy and procedure titled Cardiopulmonary Resuscitation (CPR), the facility failed to administer cardiopulmonary resuscitation (CPR) to one resident who had a Full Code status (the desire to be resuscitated in the event of cardiac/respiratory arrest) after finding him unresponsive with no respirations. This affected one (Resident #1) of three residents reviewed for Advance Directives. The facility's failure to provide CPR according to Resident #1's Advance Directives deprived him of potentially lifesaving measures. Resident #1 was not revived and expired at the facility. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 1:48 PM on [DATE]. […]

• Immediate jeopardy, isolatedF835Jun 13, 2025

  Based on staff interviews, record review, a review of the facility's policy titled Abuse Prevention and Reporting, and a review of the Agency for Health Care Administration's Background Screening Clearinghouse website, the facility's administration failed to to administer the facility in a manner that enabled it to use its resources effectively and efficiently when it failed to immediately investigate the death of Resident #1 on [DATE]. The facility failed to ensure that measures were immediately put in place for resident safety, and thorough investigations were completed to identify system failures and facility needs. This placed the facility's 47 other residents identified as having a Full Code status at risk of suffering avoidable and untimely deaths. […]

• No harm, potential for more than minimal, widespreadF812Apr 15, 2026

  Based on food service observations, staff interviews, and a review of facility policies and procedures, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, by failing to ensure food items were properly labeled and dated in both the main kitchen and nourishment rooms. This deficient practice prevents staff from determining appropriate use and increases the risk of pathogen exposure. This failure had the potential to affect all residents who consumed food items from the main kitchen and/or the facility's nourishment rooms.The findings include:On 4/13/2026 at 10:16 AM, an observation of the walk-in refrigerator revealed three Mountain Dew mini cans and one carton of yogurt stored in a bag on the top shelf with no labels or… […]

• No harm, potential for more than minimal, widespreadF812May 13, 2021

  Based on observation, staff interview and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness for all but one of the residents in the facility. The dietary staff failed to follow the proper procedures for hand hygiene, disposable glove use, food storage, date marking and proper sanitation practices in the kitchen. Specific instruction and procedures on hand hygiene, food handling and sanitation is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure. […]