Care & Rehab - Ladysmith 1

Inspectors wroteBased on interview and record review, the facility did not ensure a resident representative did not make decisions outside the scope of their role for 1 of 3 residents (R1) reviewed for Power of Attorney for finances from a sample of 5 residents.-No Power of Attorney for finances was listed prior to R1's incapacitation and due to a joint checking account with R1 and R1's Power of Attorney for health care, the facility imposed the financial duties on the Power of Attorney for healthcare.

Inspectors wroteBased on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 40 residents (R).-The facility did not complete surveillance of the onset of symptoms for resident infections. (R28, R1, and R27)-Certified Nurse Assistant (CNA) did not perform hand hygiene during water pass for R1, R6, R17, R20, and R27. -No Enhanced Barrier precautions (EBP) in place for R6 related to open wounds.-Improper PPE utilized with wound care for R6.

Inspectors wroteBased on observation, interview and policy review, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and did not 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.

Inspectors wroteBased on interview, observation and record review, the facility did not take action through documenting grievances, conducting a thorough investigation of the issues identified or providing resolution of the concerns brought to the attention of facility staff regarding missing golden necklace. 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. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure residents were free of misappropriation and/or exploitation. The facility failed to investigate and report to the State of Wisconsin or local authorities when alleged misappropriation was first reported by resident (R) R9 on 12/04/25. This led to no resolution of R9's missing golden necklace. 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.#9. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure each resident is free from unnecessary drugs as evidenced by not completing adequate drug monitoring for 1 of 5 residents (R) R9 reviewed for unnecessary medication reviews. The facility failed to accurately monitor 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. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported/reported timely for 3 of 3 residents reviewed (R7, R26, R9) to the State Agency (SA) or to law enforcement. The facility did not report R7's injury of unknown origin to the State Agency (SA) or to law enforcement. The facility did not report R26's injury of unknown origin to the SA or to law enforcement. The facility did not report misappropriation of R9's personal property to the SA or to law enforcement.

Inspectors wroteBased on interview and record review, the facility did not have evidence that all injuries of unknown origin and allegations of misappropriation of property are thoroughly investigated for 2 of 2 residents reviewed (R7, R9). R7's injury of known origin was not thoroughly investigated. R9's allegation of misappropriation of property was not thoroughly investigated.

Inspectors wroteBased on observation, interview and review, the facility did not implement the care developed in a comprehensive care plan for 1 (R16) resident of 12 residents reviewed for care plans in a sample of 12 residents. R16's comprehensive care plan was not implemented by staff regarding the placement of the torticollis orthosis (a device designed to restore proper head and neck alignment).

Inspectors wroteBased on observation, interview and record review, the facility did not revise the comprehensive care plan based on the preferences and needs of the resident for 1 (R16) resident for 12 residents reviewed for care planning in a sample of 12 residents. R16's comprehensive care plan was not revised by staff regarding the placement of the torticollis orthosis (a device designed to restore proper head and neck alignment) based on changing goals and preferences of R16.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 5 residents reviewed (R2). R2 was not repositioned per plan of care.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 of 4 residents (R6) received adequate supervision and assistance devices to prevent accidents. R6 was left unsupervised in the bathroom. Facility staff did not provide supervision or alarm system per care plan.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure pain management consistent with the comprehensive assessment and plan of care for 1 (R5) resident of 2 residents reviewed for pain management in a sample of 12 residents. R5 did not have pain assessment according to the comprehensive plan of care and physician orders documented on treatment administration record (TAR), or in medical record. This possibly resulted in R5 not attaining highest practicable level of well-being. Facility did not recognize R5's agitated and restless behaviors as possible indicators of pain through assessment and/or documentation in R5's medical record, possibly resulting in R5 not attaining highest practicable level of well-being. [...]

Inspectors wroteBased on interview and record review, the facility did not have a comprehensive system for ensuring residents received and/or were offered pneumococcal immunizations for 1 of 5 sampled residents (R) (R6). The facility did not have any documentation R6 was offered the pneumococcal vaccine, was educated on the risk and benefits of the vaccine, or that R6 declined the vaccination.

Inspectors wroteBased on interview and record review, the facility failed to report all allegations of neglect to the State Survey Agency within 24 hours for 1 of 2 allegations of abuse, neglect or mistreatment reviewed. On 09/23/25, R1 was discovered without her oxygen on and the facility investigated this as an allegation of neglect. It was not reported to the State Survey Agency until 09/30/25. This is evidenced by:The facility policy titled, Abuse-Alleged Incidents of Caregiver Misconduct and Injuries of Unknown Origin, dated revised 10/24, states in part, 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 of the facility no later than 2 hours after the allegation is made. [...]

Inspectors wroteBased 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, . [...]

Inspectors wroteBased on observation, record review and interview, the facility did not ensure the handwashing sink in the facility kitchen maintained a minimal acceptable water temperature. The facility practice had the potential to affect all residents. The handwashing sink's water temperature in the facility kitchen reached 73 degrees Fahrenheit after being ran for 2 minutes. Culinary Staff Aide (CSA) D and Culinary Manager (CM) E indicated low water temperatures have been occurring for several months and staff continued to use the sink as their means of handwashing in the kitchen. This is evidenced by: Surveyor requested and received the facility policy titled Handwashing -Food Service which was dated as most recently revised 11/12/24 and 10/18/22, prior to the current survey. The policy in part read: How to wash hands: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare and Medicaid Services (CMS). This has the potential to affect all 31 residents residing in the facility. The facility failed to enter accurate data in their Payroll Based Journal (PBJ) system which triggered that they failed to have licensed nursing coverage on 6 days. This is evidenced by: Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, states in part: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. [...]

Inspectors wroteBased on observation, record review and interview, the facility staff did not conduct hand hygiene when warranted while providing care to 1 of 3 residents observed for cares (R7). Certified Nursing Assistant (CNA) C did not perform hand hygiene when warranted when proving morning cares to R7. This is evidenced by: Surveyor requested and received the facility policy title Hand Hygiene-Employee which was dated as most recently revised on 9/24. The policy in part read: Policy: Hand hygiene continues to be the single most important thing employees can do to prevent the transmissions of infection. Consistent proper hand hygiene practices are critical in preventing the spread of infections. It is the policy of this facility that all employees follow proper hand hygiene techniques. Below is a list of some situations that require hand hygiene: ~Before and after resident contact. [...]

Inspectors wroteBased on staff interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring all allegations of abuse were reported immediately to the administrator or ensure the reporting of a reasonable suspicion of a crime in accordance with section 1105B of the Act to law enforcement for 1 of 3 residents (R) reviewed. This is evidenced by: The facility policy entitled Abuse-Alleged Incidents of Caregiver Misconduct and Injuries of unknown Origin, dated 11/09/2016 last revised 10/23 states in part, All staff will be trained to immediately report to the administrator or designee, Any form of abuse, . should be reported immediately to the Administrator or Director of Nursing. The Elder Justice Act requires notification of local law enforcement authorities of any situation where there is a potential criminal offense. [...]

Inspectors wroteBased on interview and record review, the facility did not prevent further potential abuse or mistreatment while an investigation was in progress, after an allegation of mistreatment was made against Certified Nursing Assistant (CNA) C. This is evidenced by: The facility policy and procedure entitled Abuse-Alleged Incidents of Caregiver Misconduct and Injuries of unknown Origin, dated 11/09/2016 last revised 10/23 states in part, Immediately upon learning of an incident of resident mistreatment or discovering an injury of unknown source, nursing staff must take the necessary steps to protect all residents from possible subsequent incidents of mistreatment, neglect, exploitation, or injury by removing the individual under suspicion from duty until the investigation is completed. [...]