Every finding on record at Lasell House

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.

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. Review of Medication Administration Record for Resident #20 on 9/2/23, indicated the following medications were not documented as given: -Mirtazapine 7.5 milligrams (mg) at bedtime -Simvastatin 20 mg at bedtime -Raloxifene 60 mg at bedtime -Diclofenac 1% topical gel at 9:00 P.M. -Tylenol 500 mg, 2 tablets (1000 mg) at 10:00 P.M. During an interview on 9/7/2023, the Unit Manager said he contacted the nurse who said she administered the medications to Resident #20 on 9/2/23, but forgot to document them as given.

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] . 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. The MDS also indicated Resident #23 required extensive assistance with daily tasks including bed mobility, dressing, and hygiene. 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. Resident #23 said he/she had a fall at home and had bruises and injuries. Resident #23 said the nurse changed the bandage every day. Resident #23 then acknowledged that today's date was 8/30/22, which was four days since the last dressing change. Review of Resident #23's medical record indicated the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/30/22 at 8:19 A.M., Resident #23 was observed to be fully dressed. He/she pulled up his/her sleeve and the dressing to the forearm was in place initialed and dated 8/26/22. Review of the nursing progress notes indicated the following: * 8/26/22 at 15:02 (3:02 P.M.) indicated skin tear to left forearm dry, OTA (open to air.) * 8/28/22 at 23:07 (11:07 P.M.) skin tear to left forearm dry, OTA. During an interview on 8/30/22 at 3:33 P.M., Nurse #1 said Resident #23 had a skin tear on his/her left arm that was dry and did not need a dressing. Review of the electronic treatment administration record (E-TAR) with Nurse #1, indicated the daily dressing had stopped on 8/27/22. Nurse #1 and the surveyor went to Resident #23's room and observed the left forearm dressing dated 8/26/22. Nurse #1 removed the dressing and said the area was a healed skin tear approximately four inches in length, with approximately one inch of scabbing in the middle. Nurse #1 said the dressing should have been removed. During an interview on 8/31/22 8:27 A.M. the Director of Nursing said the Resident #23's dressing on the forearm was discontinued on 8/27/22.

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. Further review of the MDS indicated Resident #23 required extensive assistance with daily tasks including bed mobility, dressing, hygiene and was at risk for developing pressure ulcers and was admitted with skin injuries. 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. Resident #23 said he/she had a fall at home and had bruises and injuries. Review of Resident #23's medical record indicated a skin evaluation dated 8/11//22. No further weekly skin evaluations were present in the medical record, indicating two weekly skin checks were not implemented by nursing staff. During an interview on 8/30/22 at 3:33 P.M., Nurse #1 said all residents have orders for weekly skin checks on the electronic treatment record (E-TAR). Nurse #1 and the surveyor observed the E-TAR for Resident #23 which only had one weekly skin check dated 8/11/22. Nurse #1 acknowledged there were no further weekly skin checks completed for Resident #23 and said there was no order in place, (for weekly skin checks.) During an interview on 8/30/22 at 4:05 P.M., the Director of Nursing said skin checks on residents are to be done weekly per facility policy and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

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. Resident #23 said he/she had a fall at home and had bruises and injuries. Resident #23 said the nurse change the bandage, daily. He/she then acknowledged that today's date was 8/30/22 which was four days since the last dressing change. Review of Resident #23's medical record indicated the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress notes indicated the following: * 8/26/22 at 15:02 (3:02 P.M.) indicated skin tear to left forearm dry, OTA (open to air.) * 8/28/22 at 23:07 (11:07 P.M.) skin tear to left forearm dry, OTA. The nursing progress notes dated 8/26/22 and 8/28/22 fail to indicate the presence of a dressing on Resident #23's forearm dated and initialed 8/26/22. During an interview on 8/30/22 at 3:33 P.M., Nurse #1 said Resident #23 had a skin tear on his/her left arm that was dry and did not need a dressing. Review of the electronic treatment administration record (E-TAR) with Nurse #1, indicated the daily dressing had stopped on 8/27/22. Nurse #1 and the surveyor went to Resident #23's room and observed the left forearm dressing dated 8/26/22.

Based on interview, record review and policy review, the facility failed to notify residents, resident representatives and families of a new COVID-19 positive staff member by 5:00 P.M. the next calendar day. Findings include: Review of the facility policy entitled, IC 405 Covid-19, dated 11/15/21, indicated that the centers (facility) must inform residents, their representatives and families of those residing in the Center by 5:00 P.M. the next calendar day following the occurrence of a single confirmed infection of Covid-19. During review of the Covid-19 Staff Surveillance Testing Log, indicated that on 8/20/22, Certified Nurse Assistant (CNA) #1 reported to work for the 3:00 P.M.-11:00 P.M. shift and was tested utilizing the Binex system. CNA #1 was found to be positive for Covid-19. During review of the progress notes, within the clinical records for 2 sampled residents (#3 and #5), from 8/20/22 through 8/31/22, indicated there was no documentation that either resident or their families/representatives were notified that a facility staff member had tested positive for Covid-19 on 8/20/22. During an interview on 8/31/22 at 11:33 A.M., the Administrator said that staff contact residents verbally and families or their representatives by phone. He said that they used to document the conversations in the resident chart, but stopped doing that in May 2022 because it was difficult to find the time to get all the information in the residents' chart.

Based on observation, record review and interview the facility failed to implement the plan of care for one Resident (#10) out of a total sample of 14 residents. Findings include: The facility policy titled Treatments, revised 11/1/19, indicated: * A licensed nurse or medical technician, per state regulations, will perform ordered treatments. Accepted standards of practice will be followed. * Document administration on the Treatment Administration Record (TAR) * Document patient's refusal of treatment on the back of the TAR and circle initials in the date and time space. Resident #10 was admitted to the facility in (MONTH) (YEAR) and had [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment indicated that Resident #10 scored a 14 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam indicating intact cognition. Additionally, according to the MDS, the resident had no behaviors. While attending a resident group meeting with the surveyor on 11/26/19 at 2:00 P.M., Resident #10's right lower leg was exposed. The surveyor observed Resident #10 had a bandage on the exposed leg. The bandage was observed to have peeling around the edges and was dated 11/18/19. During an interview with Resident #10 on 11/26/19 at 2:30 P.M., Resident #10 said that he/she had a bandage on his/her lower leg and that when the nurses changed it they wrote the date on it. Resident #10 showed the surveyor the bandaged leg dated 11/18/19. Review of Resident #10's clinical record indicated: 1.) A physician's orders [REDACTED]. 2.) A care plan for skin, dated 10/25/19, that indicated Resident #10 had several skin tears and that the staff should perform the treatment as ordered and document the treatment. During an interview with Nurse #1 on 11/27/19 at 7:20 [NAME]M., she said that when a resident had an area that required a dressing or bandage that the nurse performing the treatment would date the new bandage and document in the Treatment Administration Record (TAR) that the treatment had been completed. Nurse #1 and the surveyor observed the bandaged leg of Resident #10, the bandage was dated 11/18/19. Nurse #1 reviewed the TAR and said that the TAR indicated that the treatment had been completed on 11/21/19 and 11/24/19 by Nurse #2. During an interview with Nurse #2 on 11/27/19 at 7:28 [NAME]M., he said that he could not recall the last time that he had completed the treatment to Resident #10's right lower leg. Nurse #2 then reviewed the TAR with the surveyor and verified that he had signed the TAR on 11/21/19 and 11/24/19 as having completed the treatment to Resident #10, however had not done the treatment. Nurse #2 said he did not know why he had done that. During an interview with the Director of Nursing (DON) on 11/27/19 at 7:56 [NAME]M., she stated that it was her expectation that all treatments be done as ordered. As well, she said that the nurse should date the bandage and mark the treatment as completed in the TAR.

Based on observation, record review and interview the facility failed to accurately document treatment records for one Resident (#10) out of a total sample of 14 residents. Findings include: The facility policy titled Treatments, revised 11/1/19, indicated: * A licensed nurse or medical technician, per state regulations, will perform ordered treatments. Accepted standards of practice will be followed. * Document administration on the Treatment Administration Record (TAR) * Document patient's refusal of treatment on the back of the TAR and circle initials in the date and time space. Resident #10 was admitted to the facility in (MONTH) (YEAR) and had [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment indicated that Resident #10 scored a 14 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam indicating intact cognition. Additionally, according to the MDS, the resident had no behaviors. While attending a resident group meeting with the surveyor on 11/26/19 at 2:00 P.M., Resident #10's right lower leg was exposed. The surveyor observed Resident #10 had a bandage on the exposed leg. The bandage was observed to have peeling around the edges and was dated 11/18/19. During an interview with Resident #10 on 11/26/19 at 2:30 P.M., Resident #10 said that he/she had a bandage on his/her lower leg and that when the nurses changed it they wrote the date on it. Resident #10 showed the surveyor the leg with a bandage dated 11/18/19. Review of Resident #10's clinical record indicated: 1.) A physician's orders [REDACTED]. 2.) The (MONTH) 2019 Treatment Administration Record (TAR) indicated that the three most recent treatment's performed on Resident #10's right lower leg were done on 11/18/19, 11/21/19 and 11/24/19. On 11/27/19 at 7:20 [NAME]M., Nurse #1 and the surveyor observed the bandaged leg of Resident #10. The bandage was dated 11/18/19. Nurse #1 reviewed the TAR and said that the TAR indicated that the treatment had been completed on 11/21/19 and 11/24/19 by Nurse #2. On 11/27/19 at 7:28 [NAME]M., during an interview with Nurse #2 he said that he could not recall the last time that he had completed the treatment to Resident #10's right lower leg. Nurse #2 then reviewed the TAR with the surveyor and verified that he had signed the TAR on 11/21/19 and 11/24/19 as having completed the treatment to Resident #10, however had not done the treatment. Nurse #2 said he did not know why he had done that. During an interview with the Director of Nursing (DON) on 11/27/19 at 7:56 [NAME]M., she stated that it was her expectation that all treatments be done as ordered and accurately documented in the TAR.

Based on observation, interview and record review, the Facility staff failed to ensure that infection control practices were followed for the care of a foley catheter for 1 resident (#81) out of a total sample of 12 Residents. Findings include: Resident #81 was admitted to the Facility in 1/2019 with [DIAGNOSES REDACTED]. According to the Nursing Comprehensive Admission Data dated 1/22/19, Resident #81 has impaired long term memory and impaired short term memory. Review of the 1/2019 Treatment Administration Record indicated the following physician orders: -Foley catheter care every shift -Privacy bag and leg bag as appropriate every shift -Empty and record amount cholecystostomy tube every shift Review of the Facility policy, titled, Catheter: Indwelling Urinary - Care of, revised on 1/2/14, indicated to secure catheter tubing to keep the drainage bag below the level of the patient's bladder and off the floor. On 1/23/19 at 8:47 A.M., the Surveyor observed Resident #81 in his/her room sitting in a wheelchair. The foley catheter drainage bag was secured under the wheelchair without a privacy bag and it was touching the floor. On 1/23/19 at 3:57 P.M., the Surveyor observed Resident #81 lying in bed with the catheter drainage bag secured to the bed without a privacy bag and it was touching the floor. On 1/24/19 at 7:39 A.M., the Surveyor observed Resident #81 lying in bed with the catheter drainage bag in a privacy bag that was touching the floor. The Surveyor also observed the cholecystectomy tube touching the floor. During an interview with Nurse #1 on 1/24/18 at 7:40 A.M., she observed the foley catheter bag and cholecystectomy tube touching the floor and acknowledged that there was an infection control concern. During an interview with the Director of Nurses on 1/24/19 at 8:11 A.M., she said that drains and drainage bags should not be touching the floor.

Based on observation, record review and interviews, the facility failed to ensure that it was free of a medication error rate of 5 percent or greater. The medication pass observation was conducted on 1/19/16 and 1/20/16 with 3 nurses, for a total of 28 opportunities for error. Three medication errors affecting 1 sampled resident (#8) and 2 non-sampled residents (NS#1 and NS#2) were identified, resulting in a 10.71% medication error rate. Findings include: 1. For Resident NS#1, the facility failed to administer the correct medication. Resident NS#1 had a current physician's orders [REDACTED]. On 1/20/16 at 8:50 A.M., Nurse #1 was observed administering calcium [MEDICATION NAME] chewable (generic Tums) 500 mg to the resident and not the calcium tablet as ordered. 2. For Resident #8, the facility failed to administer the correct medication. Resident #8 had a current physician's orders [REDACTED]. On 1/20/16 at 9:25 A.M., Nurse #1 was observed pouring calcium [MEDICATION NAME] chewable (generic Tums) 500 mg. When Nurse #1 brought the medication into Resident #8, the resident stated I don't take that medication. I have been here for 5 days and I have never taken that medication. Nurse #1 stated that is your calcium. The resident stated I take a pill for that. Nurse #1 stated she would check with the Nurse Practitioner. Nurse #1 stated to the surveyor this is what we use for the calcium. NS#1 did not administer the Oyster Shell calcium 500 mg tablet as ordered. 3. For Resident NS#2, the facility failed to administer the correct medication. Resident NS#2 had a current physician's orders [REDACTED]. On 1/20/16 9:45 A.M., Nurse #2 was observed pouring calcium 500 mg tablet, not the Oyster Shell Calcium 500 mg - Vitamin D-3 200 unit tablet as ordered. Nurse #2 brought the medication into the resident's room to administer it to the resident. At that time, the Director of Nurses called Nurse #2 out of the resident's room and spoke to Nurse #2. When Nurse #2 returned, she stated the order for the calcium was being changed, so she did not administer the calcium. An interview was conducted with the Nurse Practitioner on 1/20/16 at 1:20 P.M. The Nurse Practitioner stated the facility's pharmacy does not provide the combination medication of calcium and Vitamin D-3, so the calcium and Vitamin D-3 have to be given separately. The orders for the combination medication of calcium and Vitamin D-3 come on the admission orders [REDACTED]. The Nurse Practitioner also stated that the calcium tablets and the calcium [MEDICATION NAME] chewable (generic Tums) are not interchangeable and should not have been given in place of the calcium tablets. During an interview with the Director of Nurses on 1/20/16 at 3:45 P.M., she stated that during the medication pass, it was brought to her attention that some resident's had the wrong orders for the the calcium - Vitamin D combination medication and was in the process of changing the orders.

Based on observation, documentation review and staff interview, the facility failed to insure ground meat (hamburger) was fully cooked to prevent the potential for foodborne illness. The facility served undercooked hamburgers to two sampled residents (#4 and #8) in a sample of ten and one non-sampled resident (A). Findings include: 1. On 10/15/14 at 11:45 A.M., during observation of the lunch tray line, the surveyor observed the FSD (Food Service Director) and the Food Service Dietitian take temperatures of the food held on the steam table. (Hot food held on the steamtable should be maintained at 140 degrees F. or above). A hamburger on the steamtable registered a holding temperature of 140 degrees F. The surveyor requested to see the inside of the hamburger to check if the meat was cooked completely. The FSD cut the hamburger in half and the surveyor observed that the hamburger had a brown center and was fully cooked. 2. At 12:15 P.M., the surveyor went to the residents' unit to observe lunch. In the dining room, the surveyor observed Resident #4 eating a hamburger with a pink center that indicated the hamburger was not fully cooked. The surveyor asked the resident if he/she would like the hamburger cooked more. The resident declined. At that time, the surveyor requested the FSD join the surveyor on the unit to conduct meal rounds. The surveyor and the FSD observed Resident #8 and non-sampled Resident A in their rooms eating hamburgers with pink centers. 3. At 12:30 P.M., the FSD said that some residents request medium rare hamburgers and that the facility accommodates these requests. The surveyor asked to see the kitchen's policy for cooking ground beef including the final cooking temperature required. (Ground Meat should be cooked to reach an internal temperature of at least 155 degrees F (Fahrenheit) to either kill dangerous organisms or inactivate them sufficiently to prevent foodborne illness). The FSD reported that there were no policies about final cooking temperatures. The surveyor requested to review the food temperature log where staff record food temperatures taken at each meal. The food temperature log indicated that the food temperature of entrees should register 160 degrees F or more. At 160 degrees F, a hamburger would be well done. As a result of this policy, the facility would not be able to serve medium rare hamburgers. 4. Residents #4 and #8 and Non-Sampled Resident A received hamburgers with pink centers indicating the hamburgers were not fully cooked to 160 degrees F. as per the facility policy in order to prevent the potential for food borne illness.

Based on record review, observation and staff interview, the facility failed to conduct initially and periodically a comprehensive accurate assessment for one Resident (#4), in a total sample of 10. Findings included: 1. For Resident #4, the facility failed to comprehensively assess and monitor Resident with potential for dehydration according to documented fluid requirements. Resident #4 was newly admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 6/22/11 at approximately 7:30 A.M. the Surveyor observed the Resident sitting up in bed. Upon Surveyor inquiry, the Resident was asked if staff offered fluids, to which the Resident responded "no, but I'm not thirsty at the moment." The Resident did appear to have a dry mouth at the time and appeared to be fatigued, intermittently falling back to sleep during interview. The Resident was observed in the dining room for breakfast (8:15 A.M.), lunch (12:15P.M.) and dinner (5:30 P.M.) on 6/22/11. On 6/22/11 the resident was observed to finish approximately 25% of meal and 50% of fluids, with no cueing from Certified Nursing Assistant to encourage fluids. Surveyor observation revealed the Resident in wheelchair and bed over a two day period from 6/22/11 to 6/23/11 on the 7A.M.-3:00 P.M. shift and 3:00P.M. to 6:00P.M. shift with no water pitcher at bedside and no observation of staff encouraging fluids. . Record review on 6/22/2011 revealed a "hydration protocol monitor" form with the following entries: 6/13/2011 total intake = 570cc. with no cc. documented for output. 6/14/2011 total intake = 1700cc. with "voided x 1" for urine output. 6/15/2011 total intake = 120cc. with "voided x 1" for urine output. Interview with the Speech Therapist on 6/23/2011 at 11:15 A.M. revealed that the Resident was receiving honey thickened liquids and required 1:1 supervision for risk of aspiration during meals due to newly diagnosed dysphagia. Interview with the Admitting Nurse on 6/23/2011 at approximately 12:15 P.M. revealed that the Resident was assessed to be at risk for dehydration based on UTI, dysphagia and dependence on staff. However, staff failed to accurately document the hydration protocol monitor form or assess and continuously monitor the Resident for potential dehydration based on diagnoses. Interview with the Registered Dietician on 6/23/2011 at 12:30 P.M. confirmed that the Resident's fluid requirement for a 24 hour period was 2800cc. and that fluids should be pushed. Interview with Unit 2 Nurse Manager and Director of Nursing at approximately 12:40 P.M. on 6/23/2011, revealed that "staff had dropped the ball" in assessing and monitoring the Resident's fluid requirements. A full exam of the Resident was completed by the primary care physician and forwarded to Surveyor on 6/24/2011 at 11:47 A.M.. The Resident is to be monitored for Intake and Output, with metabolic panel to be repeated on 6/27/11. The primary care physician assessed that the Resident did not appear to have a negative outcome.

Based on record review and staff interview, the facility failed to ensure the drug regimen for 1 Resident (#4) in a total sample of 10 Residents, was free from unnecessary drugs. The findings include: Resident #4 was admitted to the facility 6/12/2011 with a [DIAGNOSES REDACTED]. The Resident had been receiving [MEDICATION NAME] (a blood thinning medication) which was on hold pending blood clotting results. Record review of the interim physician's orders [REDACTED]. by mouth (PO) on 6/18/2011 for International Normalized Ratio (INR- a test to determine clotting tendency of blood) result greater than (>) 5.1. The order was transcribed to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. by mouth one time now". Further review of the MAR indicated [REDACTED]'s order. Interview with the Unit 2 Nurse Manager and Director of Nursing on 6/22/2011 @ 4:30 P.M. confirmed that the order for vitamin K was transcribed incorrectly as a one time only medication, highlighted to be administered on the wrong date and administered unnecessarily per the nurse practitioner's laboratory result parameters for INR level. Following surveyor inquiry, the unit 2 nurse manager completed an incident report, assessed the Resident and notified the Resident's family and nurse practitioner of the medication error.