Lasell House

In the surveyor’s words

From the most serious findings on record at Lasell House, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF640Sep 7, 2023

  Based on record review and interview, the facility failed to complete and submit a Discharge Minimum Data Set assessment for 1 Resident (#19) from a total sample of 13 residents. Findings include: Review of Resident #19's Discharge Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was discharged from the facility on this date. The Discharge MDS indicated Section GG (functional goals) was not completed. The Discharge MDS also indicated it was not submitted to the Center for Medicare Services (CMS). During an interview with the MDS Coordinator on 9/7/23 at 10:20 A.M., she said Resident #19's Discharge MDS (dated 4/28/23) section GG was not completed. The MDS Coordinator said the Discharge MDS was not submitted to CMS.

• No harm, potential for more than minimal, isolatedF842Sep 7, 2023

  Based on interview and record review, the facility failed to accurately document in the medical record regarding the administration of medication for 1 Resident (#20) out of a total sample of 13 residents. Findings include: Resident #20 was admitted in June 2023 with diagnoses including femur fracture, osteoarthritis, and depression. Review of Resident #20's most recent Minimum Data Set (MDS) dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15, which indicated the Resident had moderately impaired cognition. […]

• No harm, potential for more than minimal, isolatedF656Aug 31, 2022

  Based on record review and interview the facility failed to implement weekly skin checks for one Resident (#23) out of a total sample of 12 residents. Findings include: Review of the facility's policy, with a revision date of 6/1/22 indicated the following under Practice Standards: Perform skin inspection on admission/readmission and weekly. Document on Treatment Administration Record (TAR). Resident #23 was admitted in August of 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set Assessment (MDS) with an assessment reference date of 8/15/22 indicated Resident #23 scored a 13 out of 15, on the brief interview of mental status indicating he/she is cognitively intact. […]

• No harm, potential for more than minimal, isolatedF658Aug 31, 2022

  Based on observation, record review and interview the facility failed to ensure professional standards of care for one Resident (#23) out of a total sample of 12 residents, when a daily wound dressing was not removed for four days. Findings include: Review of the facility's policy, with a revision date of 6/1/22 indicated the following under Practice Standards: The implementation of an individual patient's skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed, 3.4 perform daily monitoring of wounds or dressing for presence of complications or decline and document. Resident #23 was admitted in August of 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF842Aug 31, 2022

  Based on observation, record review and interview the facility failed to ensure an accurate medical record for one Resident (#23) out of a total sample of 12 residents. Findings include: Resident #23 was admitted in August of 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set Assessment (MDS) with an assessment reference date of 8/15/22 indicated Resident #23 scored a 13 out of 15, on the brief interview of mental status indicating he/she is cognitively intact. On 8/30/22 at 8:19 A.M., Resident #23 was observed sitting up in a chair in his/her room eating his/her breakfast. Resident #23's arm was uncovered, and a dressing was on his/her left forearm, initialed and dated 8/26/22. […]