South County Eden Operations LLC Dba Lakeside Nurs

Inspectors wroteBased on clinical record review and staff interview, the facility failed to notify each resident, or resident representative, that receives Medicaid benefits when the amount in the resident's account reaches $200 less than the Social Security Income (SSI) resource limit for 3 of 4 residents reviewed who had $4000 in personal needs funds handled by the facility, Resident ID #s 42, 45, and 93.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the Centers for Medicare & Medicaid Services (CMS) System within 14 days of completion for 3 of 4 residents reviewed for MDS records over 120 days old, Resident ID #s 50, 71, and 106. Additionally, the facility failed to complete and transmit a Significant Change MDS Assessment for 1 of 2 hospice residents reviewed, Resident ID #75 and they failed to complete and transmit a discharge MDS Assessment for 1 of 3 discharged residents reviewed, Resident ID #94.

Inspectors wroteBased on surveyor observation, clinical record review, resident and staff interviews, the facility failed to provide respiratory care in accordance with professional standards of practice for 3 of 3 residents reviewed who required non-invasive positive airway pressure therapy, including Continuous Positive Airway Pressure (CPAP-a medical device that uses mild air pressure to keep the airways open during sleep) and Bilevel Positive Airway Pressure (BiPAP-a medical device that delivers higher pressure during inhalation and lower pressure during exhalation to keep the airways open during sleep), Resident ID #s 6, 7, and 35.

Inspectors wroteBased on surveyor observation, clinical record review, resident and staff interviews, the facility failed to provide written notification, including the reason for the room change, before the residents room or roommate in the facility is changed, for 2 of 2 residents reviewed for notification of room or roommate changes, Resident ID #'s 3 and 59.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that each resident receives treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan relative to 1 of 2 residents reviewed with a peripherally inserted central catheter (PICC line, a long flexible tube inserted into a vein in the arm that reaches a large central vein near the heart, used for long term intravenous treatments), Resident ID #2.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that the resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for a medication with parameters, Resident ID #6.

Inspectors wroteBased on record review, staff and resident interviews, it has been determined that the facility failed to provide the necessary services to a resident who is unable to carry out activities of daily living (ADL) for 1 of 1 resident reviewed who requires assistance with ambulation, Resident ID #2.

Inspectors wroteBased on record review, staff and resident interviews, it has been determined that the facility failed to ensure that residents who are trauma survivors, receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents experiences, and preferences, in order to eliminate, or mitigate triggers that may cause re-traumatization for 3 of 3 residents reviewed with a history of trauma, Resident ID #s 20, 51, and 83, and for 6 of 9 residents reviewed who failed to receive a comprehensive trauma screen that were admitted to the facility within the last year, Resident ID #s 11, 20, 51, 80, 89, and 294.

Inspectors wroteBased on record review and staff interview, it has been determined the facility failed to ensure that residents are free from unnecessary drugs, for 1 of 4 residents reviewed with recommendations made by the psychiatric consultant, Resident ID #89.

Inspectors wroteBased on surveyor observation, staff and resident interview, it has been determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public relative to food contact surfaces and non-food contact surfaces of equipment for 1 of 1 juice dispenser and 1 of 2 microwaves observed.

Inspectors wroteBased on surveyor observation, record review, and staff interview the facility failed to ensure that the resident environment remains free of accident hazards as is possible, for 1 of 1 resident reviewed. Specifically, Resident ID #1 who sustained 2nd degree burns (A partial-thickness burn. This type of burn affects both the epidermis and the second layer of skin, which is called the dermis. It may cause swelling and red, white or splotchy skin) from an electric baseboard heating unit.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that each resident is treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, for 1 of 3 residents reviewed, Resident ID #1.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to provide evidence that an alleged violation of abuse was thoroughly investigated, relative to staff observing a resident putting another resident's pants on of the opposite sex. Resident ID #s 3 and 8.

Inspectors wroteBased on record review, surveyor observation and staff interview, it has been determined that the facility failed to properly serve food and maintain equipment in accordance with professional standards for food safety relative to the serving temperatures of milk and the grease accumulation on the screens over the stove in the main kitchen.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that services provided by the facility meet professional standards of quality for 1 of 1 resident reviewed relative to following a physician's order for an anxiety medication, Resident ID #18.

Inspectors wroteBased on record review, resident and staff interviews, it has been determined that the facility failed to ensure that each resident receives and is provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being, in accordance with the comprehensive assessment and plan of care, for 1 of 2 residents reviewed, Resident ID #90.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and that the communication process between the facility and the hospice provider meets the needs of the resident for 1 of 2 residents reviewed who are receiving hospice services, Resident ID #18.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to staff wearing appropriate personal protective equipment (PPE) and handwashing during medication administration for 2 of 5 staff members observed, Staff D and E.