Care & Rehab - Ladysmith 1
Inspection Findings
F-Tag F0609
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility did not report an alleged violation involving mistreatment/misconduct within 24 hours of the event to the State Survey Agency. This occurred for 1 of 3 residents (R) reviewed. (Resident R1)An incident involving Resident 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 .)Resident R1 was admitted to the facility on [DATE REDACTED] with diagnoses that include congestive heart failure, chronic blood clots in vein, anemia, ovarian and rectal cancer, and GI bleed. Resident R1's most recent Minimum Data Set (MDS) dated [DATE REDACTED] indicated that Resident R1 has a Brief Interview for Mental Status (BIMS) score of 15/15 indicating intact cognition. Resident 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 [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 (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 REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
CARE & REHAB - LADYSMITH 1 in LADYSMITH, WI 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 LADYSMITH, WI, (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 CARE & REHAB - LADYSMITH 1 or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.