Lafayette Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow Centers for Disease Control and Prevention (CDC) guidelines for laundry services, failed to update their water management program to include information identified during a recent water infection control risk assessment, and failed to identify other potential risk areas in an effort to minimize the risk of Legionella that had the potential to effect the facility census of 58 residents.

Inspectors wroteBased on interview and record review, the facility failed to implement their system for monitoring antibiotic use for 5 of 7 resident reviewed for antibiotic stewardship. (Resident identifiers are #6, #7, #35, #45 and #60.)

Inspectors wroteBased on interview, and record review, the facility failed to implement a care plan for Psychotropic Medications for 1 of 5 residents reviewed for unnecessary medications in a final sample of 17 residents. (Resident identifier is #3).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with eating during meals for 1 of 2 residents reviewed for nutrition in a final sample of 17 residents. (Resident identifier is #47.)

Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions to reduce hazard(s) and risk(s) for 2 of 2 residents reviewed for elopement and for 1 of 1 resident reviewed for falls in a final sample of 17 residents. (Resident identifiers are #10, #49, and #56).

Inspectors wroteBased on interview and record review, the facility failed to provide the resident or the resident's representative with a bed hold notice that included the duration of the bed hold and reserve bed payment while hospitalized for 1 of 1 resident reviewed for hospitalizations in a final sample of 17 residents (Resident Identifier is #26).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide care consistent with professional standards of practice to promote healing for 1 of 3 residents reviewed for pressure ulcers in a final sample of 16 residents. The lack of treatment orders over a six day period resulted in a small open area that worsened into an Unstageable pressure area. (Resident identifiers is #158).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to implement policies and procedures for 2 of 2 residents observed for wound care and failed to develop a water management program to minimize the risk of Legionella that had the potential to effect the facility census of 56 residents who resided at the facility. (Resident Identifiers are #32 and #158).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to keep residents apprised of the progress towards resolution, and maintain evidence demonstrating the response and rationale of the resident group grievance for the attendees of the Resident Council Meeting for 3 of 3 months of meeting minutes reviewed.

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to develop and update comprehensive care plans for 2 of 3 residents reviewed for pressure ulcers in a final sample of 16 residents. (Resident identifiers are #32 and #158).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow physician orders for 1 of 3 residents reviewed for choices in a final sample of 16 residents (Resident Identifier is #21).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to assist a resident in gaining access to hearing services for 1 of 1 resident reviewed for communication in a final sample of 16 residents (Resident Identifier is #42).

Inspectors wroteBased on interview and record review, it was determined the facility failed to provide the necessary assistance in making transportation arrangements for a scheduled x-ray which resulted in a missed appointments for 1 of 1 resident reviewed for transportation assistance in a final sample of 16 residents. (Resident Identifier is #13.)

Inspectors wroteBased on record review and interview it was determined that the facility failed to ensure that a resident was free from abuse for 1 of 3 residents reviewed for abuse (Resident Identifier #5).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that alleged violations of abuse were reported immediately to the State Survey Agency (SSA) for 3 of 4 allegations of abuse reviewed (Resident Identifiers are #1, #2 and #3).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to revise care plans for 2 of 3 residents reviewed for abuse (Resident Identifiers are #1 and #3).

Inspectors wroteBased on observation, interview and record review it was determined that the facility failed to ensure that residents who are trauma survivors were free from re-traumatization for 1 of 1 residents reviewed for trauma (Resident Identifier #4).

Inspectors wroteBased on interview and record review it was determined that the facility failed to ensure an accurately documented medical record for 1 of 4 allegations of abuse (Resident Identifier is #1). Interview on 8/16/24 at approximately 8:30 a.m. with Staff K (Licensed Nursing Assistant) revealed that Staff K had witnessed an interaction between Resident #1 and Resident # 5 on 8/13/24 around dinner time. Interview further revealed that Resident #1 was seen touching Resident #5 on [pronoun omitted] inner thigh almost to [pronoun omitted] [genital area]. Staff K stated that he/she immediately separated the residents and reported the incident to Staff M (Licensed Practical Nurse). Interview on 8/16/24 at approximately 9:00 a.m. with Staff M revealed that he/she was the nurse on duty when the above incident occurred. [...]

Inspectors wroteBased on observation, record review, policy review, and interviews, it was determined that the facility failed to provide appropriate care and services to aide in the prevention of an avoidable pressure ulcer for 1 of 1 residents reviewed for pressure ulcers in a final survey sample of 19 residents (Resident Identifier is #48).

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards as is possible regarding storage of chemical cleaning solutions on 2 of 3 units observed (Birch Unit & Spruce Unit).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure medications were stored under proper temperature controls in 1 of 1 medication room observed and failed to ensure that open injectable medications were labeled in accordance with the manufacturer's instructions in 1 of 2 medication carts observed.

Inspectors wroteBased on observation, interview, and policy review, it was determined that the facility failed to ensure that dietary staff washed their hands before handling clean and sanitized utensils during dishwashing procedures.

Inspectors wroteBased on record review, observation, interview, and policy review, it was determined that the facility failed to follow Center For Disease Control (CDC) guidance for wearing Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) and Transmission Based Precautions (TBP) for 2 of 7 residents reviewed for infection control (Resident Identifiers are #25 and #212). Findings Include: Resident #25 Review on 5/14/24 of Resident #25's medical record revealed they received medication Intravenously (IV) and had a wound. Observation on 5/14/24 at approximately 8:30 a.m. of Resident #25 revealed an EBP sign on the door and PPE available outside of the resident's room. Further observation of Staff J (Registered Nurse) revealed while administering IV medications, they did not don a gown. Interview on 5/14/24 at approximately 8:30 a.m. with Staff J confirmed the above finding. [...]

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to develop, implement, and revise a care plan for 3 residents in a final survey sample of 19 residents (Resident Identifiers are #2, #48, and #58). Findings Include: Resident #2 Review on 5/13/24 of Resident #2's medical record revealed a diagnosis of Post Traumatic Stress Disorder (PTSD), upon admission on [DATE]. Review on 5/14/24 of Resident #2's care plan revealed no focus area or interventions related to PTSD. Interview on 5/14/24 at approximately 2:00 p.m. with Staff L (Licensed Practical Nurse) revealed they did not know the basis of Resident #2's trauma. Interview on 5/15/24 at approximately 9:55 a.m. with Staff D (Director of Nursing) confirmed the above finding. Staff D also did not know the basis of Resident #2's trauma. [...]