A list of the most recent deficiencies for Lafayette Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-18 | 2024-02-19 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-12-07 | 2024-01-12 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-11-09 | 2024-01-12 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-11-09 | 2024-01-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-09 | 2024-01-12 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-11-09 | 2024-01-12 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-09 | 2024-01-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-09 | 2024-01-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-11-09 | 2024-01-12 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-11-07 | 2024-01-10 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-11-07 | 2024-01-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-07 | 2024-01-10 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-11-07 | 2024-01-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-07 | 2024-01-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-11-07 | 2024-01-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-07 | 2024-01-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-07 | 2024-01-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-07 | 2024-01-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-09 | 2023-12-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-09 | 2023-12-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-09 | 2023-12-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-09 | 2023-12-14 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-11-09 | 2023-12-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-13 | 2023-11-20 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-09-13 | 2023-10-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-13 | 2023-10-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-13 | 2023-10-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-13 | 2023-10-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-06 | 2023-08-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-06 | 2023-08-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-07-06 | 2023-08-09 | Y |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2023-07-06 | 2023-08-09 | Y |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-07-06 | 2023-08-09 | Y |
| Provide training in compliance and ethics. | Health | 2023-07-06 | 2023-08-09 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-07-06 | 2023-08-09 | Y |
| Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | Health | 2023-07-06 | 2023-08-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-15 | 2023-07-31 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-15 | 2023-07-31 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-03-08 | 2023-04-05 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-09-28 | 2022-11-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-28 | 2022-11-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-09-28 | 2022-11-11 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-09-28 | 2022-11-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-28 | 2022-10-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-28 | 2022-10-28 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-09-28 | 2022-10-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-09-28 | 2022-10-24 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-09-28 | 2022-10-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-28 | 2022-10-24 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-09-28 | 2022-10-24 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-09-28 | 2022-10-21 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-09-28 | 2022-10-21 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-09-28 | 2022-10-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-09-28 | 2022-10-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-27 | 2022-08-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-20 | 2022-01-12 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-12-20 | 2022-01-12 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-12-20 | 2022-01-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-20 | 2022-01-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-12-20 | 2022-01-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-20 | 2022-01-12 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2021-12-20 | 2022-01-12 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-12-20 | 2022-01-12 | Y |
| Implement a program that monitors antibiotic use. | Health | 2021-08-05 | 2021-09-05 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-08-02 | 2021-09-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-02 | 2021-09-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-02 | 2021-09-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-02 | 2021-09-05 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-08-02 | 2021-09-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-08-02 | 2021-09-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-08-02 | 2021-09-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-05 | 2021-08-30 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-08-05 | 2021-08-30 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-08-05 | 2021-08-30 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-08-05 | 2021-08-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-02 | 2021-08-25 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-05-19 | 2021-06-18 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-05-19 | 2021-06-18 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-05-19 | 2021-06-18 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-19 | 2021-06-18 | Y |
