Lafayette Manor, INC

Based on the review of facility policy, observations, clinical records, and staff interviews, it was determined that the facility failed to accurately document meal consumption for six of seven residents observed. (Residents R1, R2, R3, R4, R5, and R6). Findings include: Review of the facility policy, Charting and Documentation dated 1/2/24, indicated Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. During an observation on 6/29/25, at 12:40 p.m. Resident R1's meal was noted to be approximately 25% consumed. Review of Resident R1's Task List history indicated that on 6/29/25, at 11:42 a.m. NA Employee E1 documented Resident R1's meal consumption was 75%. During an observation on 6/29/25, at 12:47 p.m. Resident R2's meal was noted to be approximately 75% consumed. Review of Resident R2's Task List history indicated that on 6/29/25, at 11:41 a.m. NA Employee E1 documented Resident R2's meal consumption was 100%. During an observation on 6/29/25, at 12:48 p.m. Resident R3's meal was noted to be approximately 25% consumed.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on a review of facility policies, observations and staff interviews it was determined that the facility failed to verify the washing temperature of the dish machine in the main kitchen, which created the potential for foodborne illness. Findings include: Review of the facility policy Automated Ware Washing Policy, dated 1/2/24, with a previous review date of 8/17/23, indicated that the dish machine will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitation. The food service manager will train staff to monitor dish machine temperatures throughout the process. Review of the facility policy Dish Machine Temperature Log, dated 1/4/24, with a previous review date of 8/17/23, indicated that dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. Temperatures for wash is identified as >/= 160 degrees, with the final rinse temperature as >/= 180 degrees. During observation of the main kitchen on 9/4/24, at 9: 30 a.m., the following was identified: The dish machine valves did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to maintain infection control practices to prevent the potential for cross contamination during a dressing change. Findings include: Review of the facility policy Dry/Clean Dressings dated 1/4/24, indicated to clean the bedside stand before and after dressing change. Tape a biohazard bag or plastic bag on the bedside stand or use the waste basket below clean field. Pull glove over old dressing and discard into plastic or biohazard bag. Cleanse the wound with ordered cleanser. Clean for the least contaminated area to the most contaminated area (usually from center outward). Review of the facility policy Infection Prevention and Control Program dated 1/4/24, indicated the infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified. Policies and procedures are utilized as the standards of the infection prevention and control program. Important facets of infection prevention include educating…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on a review of facility policy, clinical records, and incident investigation documents, it was determined that the facility failed to ensure that residents are free from misappropriation of property for three of five residents (Resident R54, R92 and R94)/ This was identified as past non-compliance. Findings include: Review of the facility Abuse Prevention Policy and Procedure dated 1/2/24, indicated that the facility will assure that the resident is free from misappropriation of property, which the policy defined as, the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident's belongings or money without the resident's consent. Review of facility provided documents indicated medications signed out by LPN Employee E6 form 8/15/24, at 7:00 p.m., shift through 8/17/24, 7:00 a.m., revealed the following: Resident R54 had 3 pills of Oxycodone 5mg (commonly referred to as Percocet, an opiod pain medication used to treat moderately severe pain) signed out, but not administered. Resident R92 had four pills of Hydrocodone/APAP 5/325mg (commonly known…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on a review of resident chosen menus, observations, resident council minutes and meeting and resident and staff interview it was determined that the facility failed to follow resident food preferences for three of four residents (Resident R63, R92 and R700). Findings include: During an observation conducted for tray accuracy on 9/5/24, for the breakfast and lunch meals it was revealed that the facility failed to provide the residents with their food preferences as follows: Breakfast Meal: * Resident R63 requested scrambled eggs and cranberry juice, the facility failed to provide either item and the resident received pancakes. * Resident R92 requested oatmeal and received cold cereal. During an interview on 9/5/24, at 8:24 a.m., Resident R63 stated that they always put on what they want to give you. During an interview on 9/5/24, at 8:25 a.m., Resident R92's representative stated that she has seen when her mother has not had items on her trays for all meals. Lunch Meal * Resident R700 wanted a hotdog and cheese curls and received a chopped hot dog and no cheese curls. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility documentation, review of cited deficiencies from the facility's abbreviated survey of 5/24/24, and staff interview, it was determined that the facility's Quality assurance and performance improvement (QAPI) program failed to correct previous cited deficiencies. This has the potential to effect all 83 residents of the facility. The findings include: The facility's deficiencies and plan of correction for the State Survey and Certification (Department of Health) survey ending May 24, 2024, revealed that the facility developed plans of corrections that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending September 6,2024, identified a repeated deficiency related to misappropriation of property and implementation of the policies and procedures to prohibit abuse and misappropriation of resident property for three of three residents. The facility QAPI Committee is responsible for the review and approval of facility policies, procedures and guidelines on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Abuse, Neglect, and Exploitation for five of ten staff members (Employees E12, E14, E15, E16, and E17). Findings include: Review of Nurse Aid (NA) Employee E12 ' s facility provided information did not include training on Abuse, Neglect, and Exploitation. Review of Registered Nurse (RN) Employee E14 ' s facility provided information did not include training on Abuse, Neglect, and Exploitation. Review of Licensed Practical Nurse (LPN) Employee E15 ' s facility provided information did not include training on Abuse, Neglect, and Exploitation. Review of LPN Employee E16 ' s facility provided information did not include training on Abuse, Neglect, and Exploitation. Review of RN Employee E17 ' s facility provided information did not include training on Abuse, Neglect, and Exploitation. During an interview on 9/6/24, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on Abuse, Neglect, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility documents and staff interview, it was determined that the facility failed to provide training on infection control for six of ten staff members (Employees E8, E12, E14, E15, E16, and E17). Findings include: Review of Nurse Aid (NA) Employee E8 ' s facility provided information did not include training on infection control. Review of NA Employee E12 ' s facility provided information did not include training on infection control. Review of Registered Nurse (RN) Employee E14 ' s facility provided information did not include training on infection control. Review of Licensed Practical Nurse (LPN) Employee E15 ' s facility provided information did not include training on infection control. Review of LPN Employee E16 ' s facility provided information did not include training on infection control. Review of RN Employee E17 ' s facility provided information did not include training on infection control. During an interview on 9/6/24, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on infection…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and observation, it was determined that the facility failed to provide an environment and care to promote dignity for each resident's quality of life for two of six sampled residents (Resident R500 and R501). Findings: Review of facility policy Resident Rights reviewed 1/4/24, indicated employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These include: a dignified existence; treated with respect, kindness, dignity, and self-determination. Review of facility policy Dignity reviewed 1/4/24, indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Demeaning practices and standards of care that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy, staff education records, and staff interview, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for two of five nurse aides (Employees E8 and E12). Finding include: Review of the facility policy, Staff Training Requirements dated 1/2/24, previously reviewed 8/17/23, indicated the facility will provide in-depth review of operational policies and procedures to all employees. All in-service training for all personnel will be conducted at a minimum of annually. Review of Nurse Aide (NA) Employees E8 and E12's education records with hire date greater than 12 months revealed the following: NA Employee E8 had a hire date of 2/28/22 with approximately 4.97 hours of in-service education between 2/28/23, and 2/28/24. NA Employee E12 had a hire date of 11/14/22, with zero hours of in-service education between 11/14/22 and 11/14/23. NA Employee E12 had not completed any in-services for 2024 as of the survey exit date of 9/6/24. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on a review of facility policy, clinical records, and incident investigation documents, it was determined that the facility failed to ensure that residents are free from misappropriation of property for 12 of 15 residents (Resident R1, R2, R3, R4, R, R6, R7, R8, R9, R10, R11, R12). This was identified as past non-compliance. Findings include: Review of the facility Abuse Prevention Policy and Procedure dated 8/17/23, indicated that the facility will assure that the resident is free from misappropriation of property, which the policy defined as, the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident's belongings or money without the resident's consent. Review of facility investigation of medications signed out by LPN Employee E1 form 5/10/24, at 1:45 p.m. through 5/11/24, at 7:15 a.m. revealed the following: -Resident R1 had three pills of oxycodone/apap (commonly referred to as Percocet, an opioid pain medication used to treat moderate to moderately severe pain) 7.5/3.5 mg signed out, but not administered. -Resident R2 had two pills of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy, resident observations, resident interviews and confidential staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of six of twelve residents (Resident R6, R14, R15, R16, and R17). Findings Include: Review of the facility policy Activities of Daily Living dated 8/17/23, indicated Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. During an interview and observation on 5/17/24, at 1:45 p.m. Resident R14 was noted to have long, jagged fingernails. When asked, Resident R14 confirmed that she would like her nails clipped. During an interview on 5/17/24, at 2:50 p.m. Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and resident and staff interview, it was determined that the facility failed to follow physician orders for medication administration for one of five residents reviewed (Resident R14). Findings include: Review of the facility's policy, Administering Medications, dated 8/17/23, indicated that medications shall be administered in a safe and timely manner, and as prescribed. Review of the clinical record indicated Resident R14 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/10/24, included the diagnoses of anemia (too little iron in the body causing fatigue), chronic kidney disease (gradual loss of kidney function), and cancer. Review of Section O: Special Treatments, Procedures, and Programs revealed the Resident R14 had received chemotherapy within the previous 14 days of the assessment. Review of Resident R14's medication administration record (MAR) dated April 2024,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of CDC (U.S. Centers for Disease Control and Prevention) documents, facility policy, clinical record review, observations and staff interviews, it was determined that the facility failed to maintain infection control procedures to prevent the possible transmission of communicable diseases for one of three residents (Resident R14). Review of the CDC document, Neutropenia and Risk for Infection dated 2/26/24, defined neutropenia as the decrease in the number of white blood cells, the body's main defense against infection, and further stated that neutropenia is common after receiving chemotherapy and increases the risk for the development of infection. The facility policy Transmission Based Precautions dated 8/17/23, indicated facility strives to maintain a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by utilizing the least restrictive precautions or isolation for the resident under certain circumstances.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical records,facility submitted documents, facility investigation information and staff interviews, it was determined that the facility failed to implement the facility abuse policy for two out of seven abuse allegations (Residents R14 and R62). Findings include: Review of the facility policy Abuse Prevention Policy and Procedure last reviewed on 8/17/23, with a previous review date of 3/1/22, indicated that the facility will assure that every resident is free from verbal, sexual and mental abuse, etc. by developing and implementing policies. Every precaution will be taken to protect residents from neglect and abuse and every allegation will be thoroughly investigated. The employee under investigation will be suspended from employment during he investigation period. Review of the clinical record indicated that Resident R14 was admitted to the facility on [DATE], with diagnoses which included anxiety, back pain, inappropriate secretion of antidiuretic hormone. A MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, clinical record and staff interview, it was determined that the facility failed to develop a baseline care plan that included risk for skin tears and interventions needed to provide effective and person-centered care for one of twelve residents (Resident R6). Findings include: Review of the facility policy Comprehensive Person-Centered Plan of Care last reviewed on 8/17/23, with previous review date of 3/1/22, indicated that a baseline plan of care will be developed within 48 hours of admission to include appropriate interventions to provide an initial set of instructions to provide effective and person centered care of the resident to meet the professional standards of quality care. Review of the clinical record indicated that Resident R6 was admitted to the facility on [DATE], with diagnoses which included cellulitis of right lower leg, vitamin B12 deficiency, eosinophilia(having too many eosinophils(white blood cells) which may contribute to inflammatory conditions) and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical records and facility policy review, and staff interview, it was determined that the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services to correct the problem for one of three residents (Resident R15). Findings include: Review of the facility policy Behavioral Management dated 8/17/23, indicated all residents receive care and services to assist in reaching and maintaining the highest level of mental and psychosocial functioning. The interdisciplinary team will review the behaviors and develop and individualized care plan to address the resident's needs. Review of the clinical record indicated Resident R15 was admitted to the facility on [DATE], with diagnoses that included encephalopathy (disease in which the functioning of the brain is affected) kidney failure, heart disease, and depression. Review of Resident R15's Minimum Data Set (MDS- assessment of a resident's abilities and care needs) dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure a medication regime was free from potentially unnecessary medication for one of five residents (Resident R15). Findings include: Review of the facility policy Psychotropic Medication Use dated 8/17/23, indicated residents will not receive PRN (as needed) doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record and non-pharmacologic interventions must be attempted and documented. Review of the clinical record indicated Resident R15 was admitted to the facility on [DATE] with diagnoses that included encephalopathy (disease in which the functioning of the brain is affected) kidney failure, heart disease, and depression. Review of Resident R15's Minimum Data Set (MDS) (assessment of a resident's abilities and care needs) dated 8/8/23, indicated that the resident had severely impaired cognition, rarely understood and understands…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of facility policy, clinical records and staff interviews, it was determined that the facility failed to maintain and complete accurate documentation for one of three residents with behaviors (Resident R15). Findings include: Review of the facility policy Behavior Management dated 8/17/23, indicated when a behavior is identified the licensed nurse will document in the clinical record and behavior records will be used. Review of the clinical record indicated Resident R15 was admitted to the facility on [DATE] with diagnoses that included kidney failure, heart disease, and depression. Review of Resident R15's Minimum Data Set (MDS) (assessment of a resident's abilities and care needs) dated 8/8/23, indicated that the resident had severely impaired cognition, rarely understood and understands others, has physical behaviors towards others, and resists care. The diagnoses remained current. Review of the nursing progress notes for Resident R15 indicated on 8/1/23, the resident became restless and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.