Care & Rehab - Ladysmith 1
CARE & REHAB - LADYSMITH 1 in LADYSMITH, WI — inspection on February 24, 2026.
Found 13 citations. 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
establish a grievance policy and make prompt efforts to resolve grievances.
documenting grievances, conducting a thorough investigation of the issues identified or providing
This affected R9.This is evidenced by:The facility policy, titled Grievance Complaint Procedures, revised October 15, 2021, states: .Procedure: #10.
Social Worker or designee will begin investigating the complaint in a timely manner to ascertain its validity and will keep a record of the investigation in the complaint file. #11. A plan of action to resolve the grievance/complaint shall be developed within 72 hours of the social worker's knowledge of the compliant.
The person filing the complaint or grievance will be informed within reasonable amount of time of the plan of action and the social worker will complete a follow-up to determine if the plan has succeeded.
The person filing the complaint or grievance will receive periodic updates throughout the process. If the plan is not successful, another plan of action will be formulated and followed.#12.
All parties involved and witnesses, if any, will be interviewed and responses recorded as a part of the investigation.
Written statements will be signed and dated by the person.#14.
The Grievance Official will work toward a solution to the problem and consult with the staff as needed .Surveyor reviewed Grievance logs dated October 2024-present (4 pages).Surveyor observed an incomplete grievance complaint form attached to grievance log, dated 12/04/25, which states in part, .[R9's] Gold necklace with (Sister) on the necklace missing.Surveyor did not see a proper investigation or process for resolution of the missing item on the incomplete grievance form. On 02/11/26 at 8:51 AM, Surveyor interviewed Social Services J and asked how Social Services J handles complaints and who oversees investigating and finding a resolution.
Social Services J reported to Surveyor that typically the staff or a resident will fill out a grievance form.
Social Services J then reviews the grievance and starts the investigation and interviews potential witnesses or resources who may know more of the situation.
Social Services J will interview the complainant and follow up through the investigation process.
Social Services J reported that Social Services J finds a resolution and makes sure to update all parties involved.
Surveyor asked how Social Services J keeps record of the steps in investigation and processes.
Social Services J reported that every complaint is documented on the grievance log and then a narrative of the steps and outcome are kept in a file folder per grievance.
Surveyor asked if Social Services J has the investigation file for R9 and what the disposition was for R9's missing Golden necklace.
Social Services J reported to Surveyor that Social Services J was out on maternity leave from 09/17/25-12/15/25, so Social Services J is unsure what came of R9's grievance.
Social Services J reported that while Social Services J was on maternity leave, Nursing Home Administrator (NHA) A was to oversee grievances.On 02/11/26 at 9:05 AM, Surveyor interviewed NHA A and asked why R9's grievance of missing Golden Necklace did not have investigation process or resolution in place. NHA A reported that NHA A didn't realize the grievance was not followed up on and that it was a mistake.
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Wisconsin or local authorities when alleged misappropriation was first reported by resident (R) R9 on
policy, titled Grievance Complaint Procedures, revised October 15, 2021, states:.Procedure:#10.
Social Worker or designee will begin investigating the complaint in a timely manner to ascertain its validity and will keep a record of the investigation in the complaint file.#9.
Consistent with CMS regulation 483.13 (c) (2), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property to the administrator and any other officials as required by State law (including the state survey and certification agency) .#11. A plan of action to resolve the grievance/complaint shall be developed within 72 hours of the social worker's knowledge of the compliant.
The person filing the complaint or grievance will be informed within reasonable amount of time of the plan of action and the social worker will complete a follow-up to determine if the plan has succeeded.
The person filing the complaint or grievance will receive periodic updates throughout the process. If the plan is not successful, another plan of action will be formulated and followed.#12.
All parties involved and witnesses, if any, will be interviewed and responses recorded as a part of the investigation.
Written statements will be signed and dated by the person.#14.
The Grievance Official will work toward a solution to the problem and consult with the staff as needed .Surveyor observed an incomplete grievance complaint form attached to grievance log, dated 12/04/25, which states in part, .[R9's] Gold necklace with (Sister) on the necklace missing.
Surveyor did not see a proper investigation or process for resolution of the missing item on the incomplete grievance form. On 02/11/26 at 8:51 AM, Surveyor interviewed Social Services J and asked how Social Services J handles complaints and who oversees investigating and finding a resolution.
Social Services J reported to Surveyor that typically the staff or a resident will fill out a grievance form.
Social Services J then reviews the grievance and starts the investigation and interviews potential witnesses or resources who may know more of the situation.
Social Services J will interview the complainant and follow up through the investigation process.
Social Services J reported that Social Services J finds a resolution and makes sure to update all parties involved.
Surveyor asked how Social Services J keeps record of the steps in investigation and processes.
Social Services J reported that every complaint is documented on the grievance log and then a narrative of the steps and outcome are kept in a file folder per grievance.
Surveyor asked if Social Services J has the investigation file for R9 and what the disposition was for R9's missing Golden necklace.
Social Services J reported to Surveyor that Social Services J was out on maternity leave from 09/17/25-12/15/25, so Social Services J is unsure what came of R9's grievance.
Social Services J reported that while Social Services J was on maternity leave, Nursing Home Administrator (NHA) A was to oversee grievances.On 02/11/26 at 9:05 AM, Surveyor interviewed NHA A and asked why R9's grievance of missing Golden Necklace did not have investigation process or resolution in place. NHA A reported that NHA A didn't realize the grievance was not followed up on and that it was a mistake.
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resident's ability to function.
unnecessary drugs as evidenced by not completing adequate drug monitoring for 1 of 5 residents (R)
resident-specific targeted behaviors for R9's psychotropic medication use.
The facility policy, titled Antipsychotic use in residents with dementia and discus requirements, dated 08/24, states: Procedure: 1.
Upon admission of a resident who has a diagnosis of dementia and is ordered an antipsychotic medication, the nursing staff will obtain from the physician an approved diagnosis for the antipsychotic medication and a specific targeted behavior/indication for it use.The facility policy further states under Procedure: 3.
The nursing department will monitor specific behavior(s) for which the antipsychotic medication was prescribed for.*Of note, the policy does not address all psychotropic medication use.R9 was admitted to facility on 10/16/25 with diagnoses that include vascular dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety and major depressive disorder.R9's physician orders include the following psychotropic medications:-Buspirone HCl Oral Tablet 15 mg.
Give 1 tablet by mouth two times a day for depression (anti-anxiety)-Trazodone HCl Oral Tablet 50 mg.
Give 1 tablet by mouth one time a day for Insomnia. (anti-depressant).-12/10/25 Paroxetine HC oral tablet 20 mg.
Give 1 tablet my mouth one time a day for major depression and anxiety.
Give 1 tablet (20 mg) with 1 (40mg) to equal 60 mg. (anti-depressant).-12/10/25 Paroxetine HC oral tablet 40 mg.
Give 1 tablet by mouth one time a day for major depression and anxiety.
Give 1 tablet (40 mg) with 1 (20mg) to equal 60 mg. (anti-depressant).R9's care plan initiated on 10/28/25 and last revised on 01/22/26 states: Focus: The resident has impaired cognitive function/Alzheimer's dementia/Vascular dementia r/t Difficulty making decisions, Psychotropic drug use.R9's care plan does not include specific focus/interventions for targeted behaviors or monitoring for all 3 psychotropic medications.R26's monitoring order for targeted behaviors related to antidepressants and anti-anxiety use was not put into place until 02/10/26 when Surveyor requested supporting targeted documentation.On 02/10/2026 at 2:15 PM, Surveyor interviewed MDS/Interim Director of Nursing (DON) B regarding R9's behavior charting and monitoring for specific targeted behaviors for use of anti-anxiety and anti-depressant medication use.
MDS/DON B stated was unable to find any supporting documentation. On 02/10/2026 at 4:15 PM, Surveyor made Nursing Home Administrator (NHA) A aware of concerns with no targeted specific behaviors being monitored for R9. NHA A stated was aware of concern and targeted behaviors were to be added for monitoring in R9's record.
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handles complaints.
On 02/11/26 at 9:05 AM, Surveyor interviewed NHA A and asked why R9's grievance of missing Golden Necklace wasn't reported to law enforcement or to the state agency. NHA A reported that NHA A didn't realize the grievance was not followed up on and that it was a mistake.
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social worker's knowledge of the compliant.
The person filing the complaint or grievance will be
receive periodic updates throughout the process. If the plan is not successful, another plan of action
#12.
All parties involved and witnesses, if any, will be interviewed and responses recorded as a part of the investigation.
Written statements will be signed and dated by the person. #14.
The Grievance Official will work toward a solution to the problem and consult with the staff as needed .
Surveyor reviewed Grievance logs dated October 2024-present (4 pages): Surveyor observed an incomplete grievance complaint form attached to grievance log, dated 12/04/25, which states in part, .[R9's] Gold necklace with (Sister) on the necklace missing.
Surveyor did not see a proper investigation or process for resolution of the missing item on the incomplete grievance form.
On 02/11/26 at 8:51 AM, Surveyor interviewed Social Services J and asked what the process is for how Social Services J handles complaints and who oversees investigating and finding a resolution.
Social Services J reported to Surveyor that typically the staff or a resident will fill out a grievance form.
Social Services J then reviews the grievance and starts the investigation and interviews potential witnesses or resources who may know more of the situation.
Social Services J will interview the complainant and follow up through the investigation process.
Social Services J reported that Social Services J finds a resolution and makes sure to update all parties involved.
Surveyor asked how Social Services J keeps record of the steps in investigation and processes.
Social Services J reported that every complaint is documented on the grievance log and then a narrative of the steps and outcome are kept in a file folder per grievance.
Surveyor asked if Social Services J has the investigation file for R9 and what the disposition was for R9's missing Golden necklace.
Social Services J reported to Surveyor that Social Services J was out on maternity leave from 09/17/25-12/15/25, so Social Services J is unsure what came of R9's grievance.
Social Services J reported that while Social Services J was on maternity leave, Nursing Home Administrator (NHA) A was to oversee grievances.
On 02/11/26 at 9:05 AM, Surveyor interviewed NHA A and asked why R9's grievance of missing Golden Necklace did not have investigation process or resolution in place. NHA A reported that NHA A didn't realize the grievance was not followed up on and that it was a mistake.
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staff apply the cushion, R16 does not complain.
When certain CNA staff apply the cushion, R16 does
R16. PT I stated cushion was to be worn by R16 at meals. PT I stated R16's compliance depended on
whole group. PT I stated individual staff training was also provided when requested to promote R16's compliance in wearing the cushion.
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is indicated for R16 and needs to be ordered by nursing staff.
Record review of R16's medical record
02/08/2026, monthly restorative/maintenance summary by nursing states: Torticollis orthosis: apply
placement of torticollis cushion 5 days in January 2026, and 5 days in February 2026. To be noted: CNA documentation on R16's compliance for use of torticollis orthosis was not completed for all days in January and February. R16's care plan, last revised on 12/23/2026, does not indicate R16's resistance to wearing torticollis orthosis. R16's care plan does not have interventions in place to promote R16's compliance when having discomfort from cushion. R16's care plan does not have interventions for alternatives to maintaining neck alignment during meal time. R16's treatment administration record does not have documentation for monitoring placement of cushion. R16 does not have orders in medical record for a PT reevaluation for placement and/or effectiveness of torticollis orthosis cushion. On 02/11/2026 at 8:35 AM, Surveyor interviewed MDS Coordinator/Interim DON B on the facility's process for updating/revising care plans when changes in a resident's care routine were acknowledged. MDS/DON B stated any nurse can make changes to a resident's care plan at any time.
Any staff discipline can notify MDS/DON B of changes in a resident's routine and ask for changes to be made in the care plan.
All care plans are reviewed and/or updated quarterly, and as needed. MDS/DON B was aware R16 did not always wear the cushion stating, [R16] is tricky sometimes.
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care in accordance with professional standards of practice and the comprehensive person-centered
include:Facility policy titled, Care Planning with Resident and/or Representative, effective 11/23/2016, reads in part: To provide a team approach in the planning and care of the resident as a whole and to periodically review this plan to attain and maintain the highest practicable physical, mental, and psychosocial wellbeing.Facility policy titled, Standards of Care, last revised 2/26, reads in part: All employees are to follow the Standards of Care for their specific job position.care plans are to be followed on all residents, at all times.
Update nurse if the care plan requires changes.R2 was admitted to the facility on [DATE].On 11/18/25, R2 had a Brief Interview for Mental Status (BIMS) of 99 indicating R2 was unable to complete the interview.R2's care plan includes in part: The resident has potential for pressure ulcer development related to immobility with an intervention of assist to shift weight in wheelchair every 15 minutes and the resident needs (reminding/assistance) to turn/reposition at least every 2 hours (8-12-25).On 02/10/26 at 7:03 AM, R2 was taken to the dining room for breakfast in R2's Broda chair.
Surveyor observed R2 until 9:18 AM. R2 was not repositioned or had weight shifted every 15 minutes per plan of care. R2 remained in Broda chair in dining room placed in front of the television.On 02/11/26 at 9:57 AM, Surveyor interviewed Certified Nursing Assistant (CNA) O. CNA O stated if CNAs need to know what care residents need, they have care plans in the computer, and the care plans are updated all the time.On 02/11/26 at 10:08 AM, Surveyor interviewed Registered Nurse (RN) D. RN D stated CNAs are expected to follow the care plans. RN D stated if the CNAs do not agree with something in the care plan, they can talk to the nurses about possible changes needing to be made. RN D stated care plans get updated as changes happen. RN D stated CNAs will get verbal reports, there is a communication board, and therapy will give both nurses and CNAs any changes made by that department.On 02/11/26 at 10:24 AM, Surveyor interviewed CNA F. CNA F stated they have care plans available to know what care the residents need. CNA F stated the care plans are found in the electronic system the facility uses, and they also have daily sheets that give them a little insight.On 02/11/26 at 10:32 AM, Surveyor interviewed Minimum Data Set (MDS) coordinator/Director of Nursing (DON) B. MDS/DON B stated MDS/DON B updates care plans at a minimum quarterly when everything is checked to make sure it is correct and up to date.
MDS/DON B stated care plans are also updated as needed when changes happen.On 02/11/26 at 10:45 AM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A stated NHA A would hope CNAs would follow the care plan. NHA A stated the care plans are available to the CNAs on the computer and they should know what their tasks are. NHA A stated CNAs have shift-to-shift reports and the floor nurses should be monitoring the CNAs for compliance. NHA A was informed about Surveyor's observation and what the care plan states.
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prevent accidents.
observation, interview, and record review, the facility did not ensure 1 of 4 residents (R6) received
bathroom.Facility staff did not provide supervision or alarm system per care plan.Findings include:Facility policy titled, Care Planning with Resident and/or Representative, effective 11/23/2016, reads in part: To provide a team approach in the planning and care of the resident as a whole and to periodically review this plan to attain and maintain the highest practicable physical, mental, and psychosocial wellbeing.Facility Policy titled, Fall Risk Management Policy, last revised 1/26, reads in part: It is the policy of {Care and Rehab-Ladysmith} to promote resident safety by identifying resident as risk for falling.as well as implement appropriate interventions to prevent continued/repeated falls.High risk fall interventions may include.Do not leave a high risk for falls resident unattended when toileting.Facility policy titled, Standards of Care, last revised 2/26, reads in part: All employees are to follow the Standards of Care for their specific job position.Residents with alarms are not to be left unattended on the toilet.R6 was admitted to the facility on [DATE].On 01/08/26, R6 had a Brief Interview for Mental Status score of 15/15 indicating cognitively intact.Surveyor reviewed most recent falls. On 12/04/25, R6 had a fall from the toilet. On 12/12/25, R6 had a fall while trying to self-transfer from recliner to bathroom. On 01/15/26, R6 had a fall from the recliner. On 02/01/26, R6 had a fall due to sliding out of his wheelchair.
Interventions in place on 12/05/25 after the fall on 12/04/25. No new interventions or revisions for most recent 3 falls.R6's care plan includes in part: Focus of self-care deficit with intervention of doorbell motion alarm in bathroom (01/06/26) and do not leave me unsupervised while toileting (12/05/25).
Focus of falls/injury with interventions of lessen my risk for falls/injury: Assure alarms are in place in case I attempt to self-transfer. Do not leave unsupervised during toileting (12/05/25).On 02/10/26 at 9:21 AM, Surveyor observed R6 on the toilet unsupervised with no alarms.On 02/10/26 at 9:23 AM, Surveyor observed Certified Nursing Assistant (CNA) O inform Registered Nurse (RN) L that R6 was in the bathroom if RN L wanted to look at R6's buttocks bandage. RN L informed Surveyor R6 was in the bathroom and RN L would be doing wound care shortly.On 02/11/26 at 9:57 AM, Surveyor interviewed CNA O. CNA O stated if a care plan states a resident should not be left alone while toileting or the resident has alarms, they cannot leave that resident unattended in the bathroom.On 02/11/26 at 10:08 AM, Surveyor interviewed RN D. RN D stated CNAs are expected to follow the care plans. RN D stated if the CNAs do not agree with something in the care plan, they can talk to the nurses about possible changes needing to be made.On 02/11/26 at 10:24 AM, Surveyor interviewed CNA F. CNA F stated CNA F would not leave a resident alone in the bathroom if they have alarms or the care plan stated they should not be left unsupervised in the bathroom.On 02/11/26 at 10:45 AM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A stated NHA A would hope CNAs would follow the care plan. NHA A stated the care plans are available to the CNAs on the computer and they should know what their tasks are. NHA A stated CNAs have shift-to-shift reports and the floor nurses should be monitoring the CNAs for compliance.
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wheelchair and incoherently verbalize to wife during interview with R5's wife. R5's wife stated R5
permanent indwelling urinary catheter because of chronic urinary retention, a condition diagnosed by
R5 because of frequent pulling on catheter tubing, at times completely dislodging catheter. R5's wife stated, I think it hurts around his penis and that is why he pulls on it. R5's wife informed Surveyor of R5's history of falls, one which resulted in fracture of left femur. R5's wife was unable to interpret if R5 was having pain during interview. On 02/10/2026 at 7:44 AM, during interview with Registered Nurse (RN) D, RN D stated R5 is up all night most nights and repeatedly attempts to exit the bed. RN D stated it is unclear to cause of R5's restlessness.
Record review of R5's medical record indicated the following: R5 suffered falls while residing at facility on 09/21/2025, 11/12/2025 and 10/15/2025.
The fall R5 had on 10/15/2025 resulted in a left femur fracture, requiring surgical intervention. On 09/09/2025, physician orders state: Ask resident if having presence of pain, aches or discomfort OR non-verbal indicators of pain (facial expressions, protective body movements, posture etc.) using the pain measurement scale of 0 -10 or FACES pain rating scale.
Document appropriate number. On 11/14/2025, physician orders state: Acetaminophen (medication for pain/fever) tablet 325mg, give 2 tablets one time a day for chronic pain. On 01/30/2026, order was discontinued. R5's TAR for January 2026 and February 2026 include directions that state: Ask resident if having presence of pain, aches or discomfort OR non-verbal indicators of pain (facial expressions, protective body movements, posture etc.) using the pain measurement scale of 0 -10 or FACES pain rating scale.
Document appropriate number. R5's TARs indicate pain assessment was done twice daily. R5's TARs have no time of day documented when assessments were done. R5's TARs do not have number indicators of R5's pain levels documented.
Daily pain assessment include check marks with initials of staff. On 12/03/2025 at 4:35 PM, nursing documentation in R5's medical record states in part, Foley catheter placed causes discomfort to resident, resident attempts to pull catheter out frequently. R5's medical record for December 2025, January 2026 and February 2026 showed several chart entries by nursing staff for behavior/mood of R5 exhibiting restless behaviors at night with attempts to get self out of bed. R5's frequently pulled at catheter tubing and at times pulled it entirely out. No documentation for pain assessment found in R5's record. On 12/10/2025 at 12:00 PM, interdisciplinary team charting stated in part: Resident throughout the month of November continued to have daily behaviors of pulling at lines (i.e. catheter), attempting to get out of chair or bed.
Resident's wife visits nearly every day and aids with behaviors and reorienting resident. On 01/17/2026 at 6:49 AM, R5's medication administration record (MAR) indicates Acetaminophen 325mg 2 tablets was administered. No pain level or reason for administration of pain medication was documented. On 02/11/2026 at 8:35 AM, Surveyor interviewed MDS coordinator/Director of Nursing (DON) B regarding what staff expectations were for assessing and documenting pain on residents who are unable to communicate verbally.
MDS/DON B stated nonverbal residents are assessed for pain using the FACES scale, and it is documented utilizing the number conversion in a resident's medical record.
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Based on observation, interview and policy review, the facility did not ensure all drugs and biologicals
ensure only authorized personnel had access to medication cabinets on 100 unit and 200 unit.
This occurred for 6 of the 26 medication cabinets outside residents' rooms observed. -During the three-day survey, 6 of 26 observations were made of individual resident (R6, R27, R17, R28, R31, and R11) medication cabinets left unlocked when unattended and out of view of staff with prescribed medications in cabinets.
Findings include: The facility policy, titled Medication Administration, revised August 2025, states: .#2.
Storage of Medications: b.
Only licensed nurses, med techs, the consultant pharmacist and those lawfully authorized to administer medications are allowed access to medications.
Medication rooms, carts, and medication supplies are locked when unattended, or attended by persons with authorized access only . On 02/10/26 at 12:04 PM, Surveyor observed medication cabinet outside R6's room unlocked.
Surveyor observed Trimacolone ointment labeled with R6's identifying information and dispersed on 04/14/24.
Surveyor observed R6's calcium alginate dressing also located in unlocked medication cabinet. On 02/10/26 at 12:05 PM, Surveyor observed medication cabinet outside R27's room unlocked.
Surveyor observed unknown white powder in a medicine cup located in unlocked medication cabinet. On 02/10/26 at 12:06 PM, Surveyor observed medication cabinet outside R17's room unlocked.
Surveyor observed arthritis cream labeled with R17's identifying information located in unlocked medication cabinet. On 02/10/26 at 12:07 PM, Surveyor observed medication cabinet outside R28's room unlocked.
Surveyor observed Difloneac cream labeled with R28's identifying information in unlocked medication cabinet. On 02/10/2026 at 12:17 PM, Surveyor observed medication cabinet outside R31's room unlocked.
Surveyor observed prescription bottle of Hibiclens and Aspercreme tube in R31's unlocked medication cabinet. On 02/10/2026 at 12:19 PM, Surveyor observed medication cabinet outside R11's room unlocked.
Surveyor observed Equate arthritic cream and Trolamine Salicylate medication in R11's unlocked medication cabinet. On 02/10/26 at 12:25 PM, Surveyor interviewed Registered Nurse (RN) L and asked if medication cabinets outside resident rooms were supposed to be locked. RN L reported that if any prescribed medication is stored in the medication cabinets, all medication cabinets should be locked.
Surveyor asked if RN L could review R6's medication cabinet. RN L stated to Surveyor, I see [R6] has Trimalicone cream that he doesn't even use anymore in the medication cabinet and that the cabinet should be locked regardless.
Surveyor observed RN L trying to lock medication cabinet right away. On 02/10/26 at 1:23 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked expectation for medication cabinets locked outside resident rooms. NHA A reported that all medication cabinets located outside resident rooms should be locked if prescribed medications are in the medication cabinet and staff are out of sight.
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EBP versus contact precautions. IP C stated, EBP is a part of contact precautions, isn't it? IP C
Minimum Data Set (MDS) coordinator/Director of Nursing (DON) B. IP C stated it was mostly from her
rest is mostly on paper. IP C stated, It's been kind of wishy-washy in some respects. IP C stated IP C was just following the education/training the staff had been provided with the year prior.
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(R6).The facility did not have any documentation R6 was offered the pneumococcal vaccine, was
include:On 2/10/26, Surveyor reviewed Pneumococcal vaccination for R6 and noted: R6 had no Pneumococcal vaccination on record and Wisconsin Immunization Registry (WIR) stated, Recommended and overdue 08/17/86.
Facility did not have any documentation of R6 declining the vaccination, nor documentation of follow-up regarding educating R6 on the risks and benefits of the vaccination.On 02/10/26 at 9:04 AM, Surveyor interviewed Infection Preventionist (IP) C and asked what the expectation is for providing pneumococcal vaccination to residents in the facility. IP C reported to Surveyor that the facility no longer offers pneumococcal vaccinations.
Surveyor asked IP C to explain IP C's process for making sure the facility is offering pneumococcal vaccines or educating residents on the risks and benefits of pneumococcal vaccination. IP C reported the facility does not offer the vaccination or complete education. IP C stated, If residents come to us wanting Pneumococcal vaccination, we refer them to the clinic to have that done.
Surveyor asked if IP C asks or updates vaccination status per resident upon admission and annually. IP C reported to Surveyor that IP C did not realize the facility had to offer pneumococcal vaccinations or offer education, so IP C stated to Surveyor, This is not being completed, and I will talk with Nursing Home Administrator (NHA) A going forward.
Surveyor asked IP C if R6 is up to date on the pneumococcal vaccinations. IP C reported R6 is not up to date on pneumococcal vaccination, and IP C does not have any declinations for R6 refusing the pneumococcal vaccination since it was not offered to R6.