Inspection visit
Inspection
8 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, record review, and review of the facility policy, the facility failed to complete a full investigation of
verbal abuse for one (Resident #44) of 54 residents and/or family members interviewed. The facility census
was 54.
Residents Affected - Few
Findings include:
Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnosis including muscle
weakness and generalized anxiety.
Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #44 was
cognitively intact and required extensive assistance of one staff for dressing.
Interview on 04/26/22 at 9:14 A.M. with Resident #44 revealed when he asked State Tested Nursing
Assistant (STNA) #523 to button his shirt, STNA #523 told him to go to [expletive]. Resident #44 revealed
this occurred a while ago while at this facility, but he was unable to recall when. Resident #44 revealed he
did speak with other staff regarding the concern.
Interview on 04/26/22 at 4:04 P.M. with the Administrator confirmed Resident #44 expressed his concern
that STNA #523 told him to go to [expletive] when he asked for assistance buttoning his shirt. The
Administrator confirmed he could not recall when this occurred but stated a complete investigation to
include suspension of STNA #523 during an investigation, interviews with additional residents and staff was
not completed by the facility since the initial allegation was made. The Administrator stated Resident #44
frequently brought up the concern.
Interview on 04/26/22 at 4:24 P.M. with STNA #523 revealed Resident #44 made this statement to several
staff members multiple times. STNA #523 revealed the accusation first occurred around December 2020
during his shift while working at this facility. He was asked by the Administrator if it occurred, and the
allegation was denied by STNA #523. STNA #523 confirmed he was not asked to leave at the time or at
any time for an investigation to occur.
Interview on 04/27/22 at 8:19 A.M. with the Facility Ombudsman revealed on 10/21/21 the Interim Facility
Ombudsman spoke to Resident #44. Resident #44 mentioned STNA #523 told him to go to [expletive]. The
Interim Facility Ombudsman notified the Director of Nursing (DON) on 10/21/21 of the concern. The Interim
Facility Ombudsman again spoke with the DON on 11/02/21 to follow up on the concern.
Review of the facility policy titled Abuse, Neglect, Exploitation, and Misappropriation of Residents Property,
dated 11/21/16, revealed it is the facility's policy to investigate all alleged
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 7
Event ID:
365891
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365891
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lafayette Pointe Nursing & Rehab Ctr
620 East Main Street
West Lafayette, OH 43845
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
Level of Harm - Minimal harm
or potential for actual harm
violations of abuse, neglect, exploitation or misappropriation of resident's property. If a staff member is
accused or suspected of abuse, neglect, exploitation, or misappropriation of resident's property the facility
should remove the staff member from the facility schedule pending the outcome of the investigation and
have evidence that all violations are thoroughly investigated.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365891
If continuation sheet
Page 2 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365891
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lafayette Pointe Nursing & Rehab Ctr
620 East Main Street
West Lafayette, OH 43845
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0685
Assist a resident in gaining access to vision and hearing services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview the facility failed to assist Resident #48 in repairing or replacing her
prescription eyeglasses when the arm of the eyeglasses broke. This affected one (Resident #48) of 54
residents and/or their family members interviewed for ancillary services provided. The facility census was
54.
Residents Affected - Few
Findings include:
Record review for Resident #48 revealed an admission date of 10/10/15 with diagnosis including need for
assistance with personal care and age-related nuclear cataracts bilateral.
Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48 was
cognitively intact. Resident #48's vision was adequate with corrective lenses.
Interview on 04/26/22 at 9:36 A.M. with Resident #48 revealed her prescription eyeglasses broke several
months ago. Resident #48 revealed she spoke with Social Service Designee (SSD) #528 at the time they
broke, but they still haven't been repaired or replaced. Resident #48 revealed she was wearing a pair of old
prescription glasses from several years ago, and she needed to frequently adjust them due to double
vision. Resident #48 revealed she felt she had no choice but to wait another month for the repair of the
glasses.
Interview on 04/28/22 at 10:03 A.M. with SSD #528 confirmed she knew about Resident #48's prescription
eyeglasses breaking. The arm of the eyeglasses broke. SSD #528 tried to take the screw out of the old pair
and put it into the new pair to fix the arm, but the screw was too big. SSD #528 confirmed there was no
documentation, and she could not recall when the glasses broke. SSD #528 confirmed the eye doctor was
scheduled to visit the facility including Resident #48 on 03/14/22. On 03/14/22 Resident #48 was in
isolation, so the eye doctor did not see her and would visit again in May 2022. SSD #528 confirmed she did
not attempt further to repair or replace Resident #48's eyeglasses.
Interview on 04/28/22 at 10:10 A.M. revealed SSD #528 called Resident #48's eye doctor. The office
confirmed they would send Resident #48 a new pair that would arrive in five to seven days.
Interview on 04/28/22 at 11:06 A.M. with SSD #528 confirmed she could have had the eye doctor fix the
eyeglasses when he was there on 03/14/22 or ordered a new pair at the time they broke. SSD #528
revealed she just didn't even think about it and figured the eye doctor would see her next time he visited in
May 2022.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365891
If continuation sheet
Page 3 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365891
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lafayette Pointe Nursing & Rehab Ctr
620 East Main Street
West Lafayette, OH 43845
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, staff interview, resident interview, observations, and policy review the facility failed to
administer oxygen as ordered by the physician. This affected two residents (Resident's #60 and #18) of two
residents reviewed for respiratory care. The facility census was 54.
Residents Affected - Few
Findings include:
1. Review of the medical record for Resident #60 revealed an initial admission date of 12/21/16 and a
re-entry date of 05/28/17. Diagnoses included chronic obstructive pulmonary disease (COPD), obstructive
sleep apnea (OSA), chronic congestive heart failure (CHF), and anemia.
Review of the physician orders for April 2022 identified an order dated 03/20/20 for observations to ensure
Resident #60 avoided lying flat, related to shortness of breath or trouble breathing related to a diagnosis of
CHF.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #60 had
intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 out of 15 (no impairment) and no
noted behaviors. The resident required extensive assistance of one to two staff members for all activities of
daily Living (ADL) except eating which he required set-up and supervision. Further review of the MDS
revealed Resident #60 received oxygen therapy.
Review of the plan of care dated 04/10/22 revealed Resident #60 was anemic. Interventions included
alerting the nurse if the resident complains of/or exhibits signs/symptoms of fatigue, skin pallor, shortness
of breath, lightheadedness, dizziness, or a fast heartbeat.
Review of the plan of care dated 04/10/22 revealed Resident #60 had cardiac symptoms due to CHF,
hypertensive heart disease, and COPD. Interventions included oxygen per orders.
Review of the plan of care dated 04/10/22 revealed Resident #60 had a diagnosis of COPD and exhibited
shortness of breath while lying flat in relation to an active diagnosis of CHF, chronic kidney disease (CKD),
COPD, and asthma.
Review of the plan of care dated 04/10/22 revealed Resident #60 was at risk for impaired respiratory
function or respiratory infection related to a history of COVID-19 virus, COPD, and CHF. Interventions
included oxygen as ordered.
Review of the Electronic Treatment Administration Record (ETAR) revealed Resident #60's order for
continuous oxygen, per nasal cannula, at two to four liters per minute to maintain oxygen saturation above
90 percent (%) was signed off every day in April 2022. Further review of the ETAR revealed Resident #60
was intermittently wearing zero to two liters of oxygen.
Review of the plan of care dated 04/10/22 revealed Resident #60 had a self-care deficit, requiring
assistance with ADL due to arthritis, pain, spinal stenosis, obesity, resident continued to sleep in her
recliner chair due to shortness of breath lying flat. Interventions included monitoring as needed (prn) for
changes in resident's abilities and adjust amount of assistance provided based on resident's needs.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365891
If continuation sheet
Page 4 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365891
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lafayette Pointe Nursing & Rehab Ctr
620 East Main Street
West Lafayette, OH 43845
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Level of Harm - Minimal harm
or potential for actual harm
Review of the progress note dated 04/18/22 at 10:27 A.M. by Registered Nurse (RN) #536 revealed
Resident #60 had COPD and wore oxygen at night.
Review of physician orders for April 2022 identified an order dated 04/21/21 for continuous oxygen, per
nasal cannula, at two to four liters per minute to maintain saturation above 90 %.
Residents Affected - Few
Observation and interview on 04/25/22 at 7:34 P.M. of Resident #60 revealed her oxygen concentrator was
running, but Resident #60 was not utilizing the oxygen. The resident revealed she wore her oxygen at night.
Observations on 04/26/22 at 8:02 A.M., 04/26/22 4:15 P.M., and 04/27/22 9:01 A.M. revealed Resident #60
was sitting in her room, with no oxygen in place.
Interview on 04/26/22 at 4:15 P.M. with RN #533 confirmed Resident #60 only wore oxygen at night and did
not need it throughout the day.
Review of the facility policy titled Respiratory: Oxygen Administration via Nasal Cannula, revised 08/25/12,
revealed the facility required a physician order to be obtained prior to the administration of oxygen via nasal
cannula. The orders for oxygen via nasal cannula must state the liter flow and specific weaning criteria.
2. Review of the medical record for Resident #18 revealed an admission date of 03/03/22. Diagnoses
included asthma, acute respiratory failure, carcinoma in the SITU (a term used to define and describe a
cancer that is only present in the cells where it started and has not spread to any nearby tissues) of the
unspecified bronchus and lung, pleural effusion, acute on chronic CHF, anemia, pneumonia, malignant
carcinoma tumor of the bronchus, and iron deficiency anemia.
Review of the physician orders for April 2022 identified an order dated 03/07/22 for continuous oxygen per
nasal cannula to maintain saturation above 90 % and to check Resident #18's oxygen saturation every shift
while on oxygen.
Review of the ETAR revealed the orders dated 03/07/22 for continuous oxygen per nasal cannula to
maintain saturation above 90 % and to check Resident #18's oxygen saturation every shift while on oxygen,
were checked off as completed every day of April 2022.
Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #18 had intact cognition with
a BIMS score of 15 out of 15 (no impairment) and no documented behaviors. Resident #18 required limited
to extensive assistance of one staff member for all ADL except eating which he required set-up and
supervision and personal hygiene which he was independent. Further review of the MDS revealed the
resident received oxygen therapy.
Review of the plan of care dated 04/22/22 revealed Resident #18 did not have an oxygen therapy care plan.
When the Director of Nursing (DON) was asked for an oxygen care plan, she provided the surveyor with the
care plan for altered health maintenance related to progressive physical and mental status: right and left
lung cancers undergoing treatment until recent illness, Fournier's gangrene with surgical debridement and
s/p catheter placement, had hypertension (HTN), hyperkeratosis lenticularis perstans (HLP), asthma,
transcatheter aortic valve placement, anemia, atrial fibrillation, and diabetes mellitus. Interventions included
medications as ordered.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365891
If continuation sheet
Page 5 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365891
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lafayette Pointe Nursing & Rehab Ctr
620 East Main Street
West Lafayette, OH 43845
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of the progress note dated 04/26/22 at 8:45 A.M. by RN #553 revealed shortness of breath on
exertion which was relieved by rest and/or oxygen. Resident #18 had been using supplemental oxygen less
and remains above 95% on room air (RA).
Review of Resident #18's oxygen saturations revealed no concerns. The oxygen saturations were
intermittently RA and intermittently on oxygen.
Interview on 04/26/22 at 4:15 P.M. with RN #533 confirmed Resident #18 only wore oxygen at night and did
not need it throughout the day.
Review of the facility policy titled, Respiratory: Oxygen Administration via Nasal Cannula, revised 08/25/12,
revealed the facility required a physician order to be obtained prior to the administration of oxygen via nasal
cannula. The orders for oxygen via nasal cannula must state the liter flow and specific weaning criteria.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365891
If continuation sheet
Page 6 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365891
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lafayette Pointe Nursing & Rehab Ctr
620 East Main Street
West Lafayette, OH 43845
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews and record review, the facility failed to ensure Resident #50's medical record accurately reflected
the correct weights. This affected one (Resident #50) of three residents (Resident's #26, #39 and #50)
reviewed for nutrition and weight loss. The facility census was 54.
Findings include:
Review of the medical record revealed Resident #50's was admitted on [DATE]. Diagnoses included
gastrostomy status (tube to feed resident), Parkinson's disease, muscle wasting and atrophy, and severe
intellectual disabilities.
Review of Resident #50's weights revealed on 12/22/21 he weighed 166.4 pounds (lbs.), 12/27/21 was 165
lbs., 01/03/22 was 165 lbs., 01/10/22 was 166 lbs., 01/17/22 was 166 lbs., 02/02/22 was 119.6 lbs.,
02/07/22 was 119.8 lbs., 02/14/22 was 122 lbs., 02/24/22 was 122.4 lbs., 02/28/22 was 122 lbs., 03/07/22
was 121.8 lbs., 03/14/22 was 117 lbs., 03/21/22 117.5 lbs., 03/28/22 was 120.5 lbs., 04/02/22 was 122 lbs.,
04/04/22 was 120 lbs., 04/11/22 was 123.7 lbs., 04/13/22 was 124 lbs., 04/18/22 was 121 lbs. and on
04/25/22 was 124.8 lbs.
Review of Resident #50's hospital Discharge summary dated [DATE] revealed he weighed 113 pounds.
Interview on 04/27/22 at 9:00 A.M. with Dietician #567 revealed there was a discrepancy with the weights
from 12/22/21 through 01/17/22. She verified the weights on 12/22/21, 12/27/21, 01/03/22, 01/10/22 and
01/17/22 were inaccurate. Dietician #567 stated Resident #50 was stable with nutrition, laboratory findings
and had no change in appearance from 01/17/22 to 02/02/22 when there was a 46.8-pound weight loss.
She verified findings from the hospital discharge paperwork stating Resident #50 weighed 113.
Interview on 04/27/22 at 3:12 P.M. with the Director of Nursing (DON) verified Resident #50's weights from
12/22/21 through 01/17/22 were inaccurate.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365891
If continuation sheet
Page 7 of 7
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Back to topCitations
8 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0351GeneralS&S Epotential for harm
Install an approved automatic sprinkler system.
- 0521GeneralS&S Fpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
F913 - Have direct access to an exit corridor;
Ensure operating rooms are properly protected and written records are maintained and available for inspection.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F685 - Vision and hearing
Assist a resident in gaining access to vision and hearing services.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the April 28, 2022 survey of LAFAYETTE POINTE NURSING & REHAB CTR?
This was a inspection survey of LAFAYETTE POINTE NURSING & REHAB CTR on April 28, 2022. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LAFAYETTE POINTE NURSING & REHAB CTR on April 28, 2022?
Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and maintain an Emergency Preparedness Program (EP)."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.