Federal Nursing-Home Survey Record
LAFAYETTE MANOR
Does LAFAYETTE MANOR have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), LAFAYETTE MANOR (CCN 525362), in DARLINGTON, WI, has federal inspection findings on its record.
In its current inspection cycle, CMS cited the facility for 11 deficiencies; the most serious carries scope/severity G on CMS's A–L scale, a level CMS classifies as actual harm. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. CMS has $159,661 in civil money penalties on file against the facility. This page restates the federal record as published by CMS and draws no conclusion of its own. Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
The Federal Record
At its most recent federal inspection, CMS cited this facility for 1 actual-harm deficiency.
Below is this facility's federal survey record as on file with CMS.
Scope & Severity — current cycle
CMS's own A–L scope/severity grid. Plotted cells mark this facility's most recent (current-cycle) citations.
Civil money penalties on file
$159,661
CMS also records 137 days of payment denial.
You may be reading this record for the first time.
If something happened to someone you love at this facility, this federal record may be new to you today. The company that operates a nursing home, by contrast, is rarely seeing records like this for the first time — operators like these typically retain standing legal, risk, and insurance teams whose routine work includes records exactly like the one on this page. That is not a judgment of this facility; it is how the business is structured. Because strict time limits can apply, families often find it helps to have a qualified person review the record with them sooner rather than later.
Overall CMS star rating
This facility: 2 · CMS state average: 3.0
Both figures as published by CMS.
Deficiency timeline
"Current cycle" is CMS's most recent inspection cycle; it can span several survey dates and is listed by scope/severity (most severe first), not chronologically. Older cycles are shown as historical.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide and implement an infection prevention and control program.
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Respond appropriately to all alleged violations.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Provide care or services that was trauma informed and/or culturally competent.
Implement a program that monitors antibiotic use.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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.
44 citations from earlier inspection cycles — historical (expand)
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Provide and implement an infection prevention and control program.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Respond appropriately to all alleged violations.
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.
Provide enough food/fluids to maintain a resident's health.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Respond appropriately to all alleged violations.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Implement a program that monitors antibiotic use.
Provide and implement an infection prevention and control program.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Respond appropriately to all alleged violations.
Ensure medication error rates are not 5 percent or greater.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
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.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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.
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Respond appropriately to all alleged violations.
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.
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Provide training in compliance and ethics.
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Document what happened
Have a concern about care at LAFAYETTE MANOR?
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