Care & Rehab - Ladysmith 1
CARE & REHAB - LADYSMITH 1 in LADYSMITH, WI — inspection on August 11, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
authorities.
interview and record review, the facility did not report an alleged violation involving
1 of 3 residents (R) reviewed. (R1)An incident involving R1 and Registered Nurse (RN) C occurred on 07/17/25. RN C did not transcribe a physician order to discontinue an anticoagulant medication and administered the medication without a physician order.
The facility did not report the misconduct to the State Survey agency until 07/24/25.The facility policy titled, Abuse - Alleged Incidents of Caregiver Misconduct and Injuries of Unknown Origin, dated May 2025, states, .
All alleged violations involving, abuse, neglect, exploitation, mistreatment, misappropriation of a resident property or injuries of unknown source are to be reported immediately to the Administrator and the appropriate units DON of the facility no later than 2 hours after the allegation is made.
All alleged violations will be reported, no later than 24 hours, to other officials (including the State Survey Agency .)R1 was admitted to the facility on [DATE] with diagnoses that include congestive heart failure, chronic blood clots in vein, anemia, ovarian and rectal cancer, and GI bleed. R1's most recent Minimum Data Set (MDS) dated [DATE] indicated that R1 has a Brief Interview for Mental Status (BIMS) score of 15/15 indicating intact cognition. R1 is able to eat with set up, independent with bed mobility, and requires partial moderate assistance for transfer and toileting.Misconduct occurred on 07/17/25 at 1841 (6:41 PM) and was discovered on 07/18/25.
Misconduct incident report states, Resident [R1] was having some bleeding issues and was on anticoagulant medication.
Nurse discussed with physician and received an order to discontinue the medication.
Resident (R1) who is her own person insisted on getting the medication, per residents rights, nurse did administer the medication causing a medication error.
The nurse was following resident wishes and did not follow doctor order.The initial facility reported incident was submitted to the state agency on 07/24/25 with the final report.
Under the brief summary of incident, facility noted, Added this incident to the final report (submitted when did not have access to system) see follow up report.
The initial report was submitted with the final report on 07/24/25 at 9:43 AM.On 08/11/25 at 12:55 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked about the timing of the initial report. NHA A stated they were aware the initial report was late because there were a lot of issues going on at the same time and NHA A had trouble getting into the system.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.