Care & Rehab - Ladysmith 1

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. (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.

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