Lafayette Pointe Nursing & Rehab Ctr
Inspection Findings
F-Tag F0880
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, interview and facility policy review the facility failed to maintain enhanced barrier precautions (EBP) during wound care for a resident with a pressure injury. This deficient practice affected one resident (Resident #35) out of three residents reviewed for infection control. The facility census was 58.Findings Include:Review of Resident #35's medical record revealed an admission date of 04/21/23 with diagnoses including but not limited to type two diabetes, Peripheral Vascular Disease (PVD), edema, and depression.Review of Resident #35's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE REDACTED] revealed Resident #35 had intact cognition, had an unhealed stage three pressure injury and surgical wounds were present.Review of Resident #35's physician orders revealed an order dated 10/26/25 to cleanse left outer heel with normal saline (NS) and apply a layer of hydrogel and cover with an abdominal dressing and gauze daily and as needed (PRN) for wound care, and an order dated 11/18/25 for Enhanced Barrier Precautions (EBP) for wounds.An observation was conducted on 11/19/25 from 1:32 P.M. to 1:45 P.M. of Licensed Practical Nurse (LPN) #220 completing wound care and dressing change to Resident #35's left outer heel pressure injury. Resident #35's door had a sign indicating Resident #35 was on EBP for wound care, and staff were to wear a gown and gloves while completing the task. LPN #220 entered the room, washed hands and put gloves on prior to removing the soiled dressing and disposing of the dressing
in the trashcan. LPN #220 removed the soiled gloves, washed hands and placed clean gloves on to cleanse
the left outer heel pressure injury with normal saline and gauze. LPN #220 placed the used gauze in the trashcan, washed hands and placed a clean pair of gloves on to place the medication and clean dressing in place. LPN #220 completed the dressing change, removed the towel barrier and placed the dressing packaging in the trashcan, washed hands and exited the room. LPN #220 did not place a gown on during wound care and dressing change for Resident #35.An interview on 11/19/25 at 1:45 P.M. with LPN #220 confirmed a gown was not worn during the wound care and dressing change for Resident #35 requiring EBP due to having wounds. LPN #220 also confirmed the EBP sign located on Resident #35's door indicated the use of a gown during high contact resident care activities, which included wound care.Review of the facility policy titled Standard and Transmission-Based Precautions dated 03/24/24 revealed Enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.This deficiency represents non-compliance investigated under Complaint Number 2644903.
Residents Affected - Few
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
Event ID:
LAFAYETTE POINTE NURSING & REHAB CTR in WEST LAFAYETTE, OH inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WEST LAFAYETTE, OH, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LAFAYETTE POINTE NURSING & REHAB CTR or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.