Inspection Reports for South County Eden Operations LLC DBA Lakeside Nursing and Rehabilitation
740 OAK HILL ROAD, NORTH KINGSTOWN, RI, 02852
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
68% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Plan of Correction
Deficiencies: 0
May 22, 2025
Visit Reason
An off-site desk audit was conducted on May 22, 2025, to review all previous deficiencies cited on April 17, 2025.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 4
Apr 17, 2025
Visit Reason
A Recertification Survey and complaint investigation were conducted from 4/14/2025 through 4/16/2025 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a State licensure and emergency preparedness survey.
Findings
Deficiencies were cited related to failure to provide necessary care and services for activities of daily living, including ambulation assistance, and failure to ensure trauma-informed care for residents who are trauma survivors. Additional deficiencies included failure to ensure residents are free from unnecessary drugs and failure to maintain a safe, functional, and sanitary environment.
Complaint Details
The visit included a complaint investigation with ACTS Reference Numbers 100413 and 100414. The complaint investigation focused on failure to provide necessary care and services to residents, including ambulation assistance and trauma-informed care.
Severity Breakdown
SS=E: 2
SS=D: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to provide necessary services to ensure a resident's abilities in activities of daily living, specifically assistance with ambulation for Resident ID #2. | SS=E |
| Facility failed to ensure trauma-informed care for residents who are trauma survivors, including failure to complete trauma screening assessments and develop trauma-informed care plans for affected residents. | SS=E |
| Facility failed to ensure residents are free from unnecessary drugs for 1 of 4 residents reviewed with recommendations made by psychiatric consultant. | SS=D |
| Facility failed to provide a safe, functional, and sanitary environment, including accumulation of dried residue in a juice dispenser nozzle and unclean microwave used to heat resident food. | SS=D |
Report Facts
Residents reviewed for trauma screening: 9
Residents with trauma screening and care plans: 6
Residents reviewed for unnecessary drugs: 4
Dates of therapy for Resident ID #2: 2025-01-03 to 2025-01-24
Dates of medication administration review: 2025-03-05 to 2025-03-10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Nursing Assistant | Revealed he does not assist Resident ID #2 with walking and was unaware of the resident's Safe Patient Handling form. |
| Staff B | Physical Therapist | Revealed Resident ID #2 has a Safe Patient Handling form and functional decline while off therapy. |
| Staff C | Licensed Practical Nurse | Revealed she has not observed staff walking the resident and references the Safe Patient Handling form. |
| Staff D | Nursing Assistant | Cares for the resident on the 11:00 PM - 7:00 AM shift and does not assist with ambulation. |
| Director of Nursing Services | Director of Nursing (DNS) | Acknowledged lack of restorative therapy program and inability to provide evidence of ambulation assistance. |
| Director of Rehabilitation Services | Director of Rehabilitation Services | Revealed resident was discharged from therapy and readmitted for decreased ambulation. |
| Director of Social Services | Director of Social Services | Acknowledged failure to complete trauma screening admission assessments. |
| Food Service Manager | Food Service Manager (FSM) | Responsible for implementing plan of correction related to sanitation and cleanliness of food service equipment. |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 10, 2024
Visit Reason
An off-site desk audit was conducted on June 10, 2024, to review all previous deficiencies cited on April 22, 2024.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Recertification Survey
Census: 104
Capacity: 120
Deficiencies: 7
Apr 22, 2024
Visit Reason
A Recertification Survey and complaint investigation were conducted from 4/17/2024 through 4/22/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were cited related to professional standards of care, behavioral health services, food safety, hospice services, infection control, medication administration, personnel records, and life safety code compliance. The facility failed to meet several regulatory requirements as evidenced by observations, record reviews, and staff interviews.
Complaint Details
The survey included complaint investigations with ACTS Reference Numbers 95109, 94821, 94988, and 95248. The complaint investigation focused on medication administration, behavioral health services, and infection control. Some complaints were substantiated as evidenced by deficiencies cited.
Severity Breakdown
Level D: 5
Level F: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Services provided did not meet professional standards of quality for one resident related to anxiety medication orders. | Level D |
| Behavioral health services requirement not met for one resident. | Level D |
| Food safety requirements not met related to serving temperatures and grease accumulation in kitchen. | Level F |
| Hospice services requirements not met including documentation and coordination of care. | Level D |
| Infection prevention and control program deficiencies including PPE use and hand hygiene. | Level D |
| Personnel records did not include evidence of active licensure for one nurse and incomplete quarterly medication technician evaluations. | Level D |
| Life Safety Code deficiencies related to sprinkler system maintenance and obstruction. | Level F |
Report Facts
Capacity: 120
Census: 104
Dates of survey: 2024-04-17 to 2024-04-22
Medication administration observations: 2
Sprinkler system coverage: 104
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Observed providing care and involved in medication administration deficiency |
| Staff D | Nurse | Observed not wearing PPE properly during medication administration |
| Staff E | Nurse | Observed not wearing PPE properly during medication administration |
| Staff F | Licensed Practical Nurse | Found to lack active nursing license during personnel record review |
| Director of Nursing | Responsible for ensuring Plan of Correction execution and compliance | |
| Director of Human Resources | Responsible for ensuring personnel licensure compliance | |
| Director of Maintenance | Responsible for sprinkler system maintenance and compliance |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 12, 2023
Visit Reason
An off-site desk audit was conducted on April 12, 2023 for all previous deficiencies cited on March 2, 2023 to verify correction.
Findings
Based on an acceptable plan of correction, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 6
Mar 2, 2023
Visit Reason
A Recertification Survey and complaint investigation were conducted at South County Nursing and Rehabilitation Center from 2/28/2023 through 3/2/2023 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a State licensure and emergency preparedness survey.
Findings
Deficiencies were cited related to Medicaid/Medicare Coverage/Liability Notice, Accuracy of Assessments, Development and Implementation of Comprehensive Care Plans, Services Provided Meeting Professional Standards, Free of Accident Hazards/Supervision/Devices, and Safe/Functional/Sanitary/Comfortable Environment. The facility submitted a Plan of Correction addressing each deficiency with corrective actions and completion dates.
Complaint Details
Complaint investigation was conducted as part of the recertification survey, with ACTS #s 89219 and 89235. Deficiencies were substantiated as a result of the complaint investigation.
Severity Breakdown
SS=D: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility failed to properly provide notice to residents and/or representatives regarding changes in coverage for Medicare and Medicaid services, specifically the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) for 2 of 3 residents discharged from Medicare Part A Services. | SS=D |
| Facility failed to ensure assessments accurately reflected residents' status for 4 of 8 residents reviewed relative to wandering risk assessments. | SS=D |
| Facility failed to develop and implement a comprehensive care plan for a resident reassessed and no longer presenting as at risk for wandering/elopement. | SS=D |
| Facility failed to assure services being provided met professional standards of quality related to physician's orders for 2 of 8 residents reviewed. | SS=D |
| Facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident at risk for elopement. | SS=D |
| Facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, including proper hand hygiene and ice scoop handling. | SS=D |
Report Facts
Residents reviewed for wandering risk assessments: 8
Residents discharged from Medicare Part A Services: 3
Residents reviewed for professional standards: 8
Residents observed for sanitary environment: 4
Residents observed for hand hygiene: 4
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