Health inspection·June 29, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. 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. Review of Resident R3's Task List history indicated that on 6/29/25, at 11:42 a.m. NA Employee E1 documented Resident R3's meal consumption was 75%. During an observation on 6/29/25, at 12:50 p.m. Resident R4's meal was noted to be approximately 100% consumed. Review of Resident R4's Task List history indicated that on 6/29/25, at 12:29 p.m. NA Employee E2 documented Resident R4's meal consumption was 75%. During an observation on 6/29/25, at 12:51 p.m. Resident R5's meal was noted to be approximately 25% consumed. Review of Resident R5's Task List history indicated that on 6/29/25, at 12:27 p.m. NA Employee E2 (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 2 Event ID: 395795 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 395795 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lafayette Manor, Inc 147 Lafayette Manor Road Uniontown, PA 15401 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)