Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Care & Rehab - Ladysmith 1 during CMS and state inspections, most recent first.
Infection prevention and control was not consistently carried out in the facility. Infection line lists for residents with respiratory symptoms lacked documentation of isolation type, testing, and well dates, and the IP stated the process had not been consistently documented and that testing beyond COVID was not always understood or completed. During water pass, a CNA did not perform hand hygiene between resident rooms, and during wound care for a resident with stage 3 buttock wounds, staff wore gloves but no gowns despite EBP signage and policy requiring gown and glove use for high-contact care.
Unsecured medication cabinets outside resident rooms contained prescribed creams, dressings, a prescription bottle, and an unknown white powder, and 6 of 26 observed cabinets were left unlocked when unattended and out of view of staff. Facility policy required medication storage to be locked when unattended, and an RN and the NHA both stated the cabinets should be locked when prescribed meds were present.
A resident’s grievance about a missing gold necklace was documented incompletely and lacked a proper investigation or resolution. Survey review found no clear follow-up, and interviews showed the Social Services designee was on leave while the NHA was supposed to oversee grievances, but the complaint still was not addressed.
Failure to investigate a missing resident necklace: The facility did not properly follow up on a grievance about a gold necklace that was reported missing, and there was no documented investigation or resolution. Interviews showed the grievance process was not completed while Social Services was on leave, and the NHA acknowledged the complaint was not followed up on.
A resident with vascular dementia, anxiety, and major depressive disorder had orders for Buspirone, Trazodone, and Paroxetine, but the facility did not document resident-specific targeted behaviors or monitoring for the psychotropic medications. The care plan did not include specific behavior-focused interventions for all three medications, and the MDS/DON could not find supporting behavior charting when surveyed.
Failure to Report Alleged Abuse, Injuries of Unknown Source, and Missing Property: The facility did not timely report an alleged abuse incident involving a resident with two skin tears, did not report another resident’s unexplained ankle injury and fracture, and did not report a missing gold necklace belonging to a third resident. Records showed the first incident was not reported to the State within the required timeframe and law enforcement was not contacted. The NHA stated the facility did not call law enforcement because it could not prove abuse and later acknowledged the other incidents were not reported because they were not recognized as reportable.
The facility failed to thoroughly investigate a resident's unexplained skin tears and a separate grievance involving a missing gold necklace. A resident with dementia and moderate cognitive impairment was found with two right forearm skin tears during morning care, but the accused CNA was allowed to finish the shift and the investigation did not include adequate interviews or immediate management notification. The facility also had no proper investigation or resolution documented for a resident's missing necklace grievance.
A resident with Alzheimer's disease, stroke-related hemiplegia, epilepsy, dysphagia, aphasia, and moderate cognitive impairment did not receive care as outlined in the care plan for a torticollis orthosis during meals. Staff observed the resident being fed without the orthosis cushion in place, with feeding done from the resident's right side instead of the planned positioning. The resident said the cushion was not being used, he could not feed himself, and swallowing was hard because of neck flexion to the right; CNA, OT, and PT interviews confirmed the orthosis was intended for mealtime use but was inconsistently applied depending on the staff member.
A resident with Alzheimer’s disease, prior stroke, dysphagia, and aphasia had a care plan for a torticollis orthosis to be worn during meals, but staff observed the cushion was often not in place. The resident said it hurt and did not like it, and CNA, RN, OT, and PT interviews confirmed inconsistent use and discomfort. The care plan did not reflect the resident’s resistance, discomfort, or alternatives for neck alignment, and documentation of use was incomplete.
A resident with immobility-related pressure ulcer risk was observed sitting in a Broda chair in the dining room for over 2 hours without the required weight shifts every 15 minutes or repositioning per the care plan. Staff interviews confirmed that care plans were available in the electronic system and were expected to be followed by CNAs, with the RN, MDS/DON, and NHA all acknowledging that resident care plans guide daily care.
Failure to supervise a fall-risk resident during toileting. A cognitively intact resident with multiple recent falls had care plan interventions for a bathroom motion alarm and for not being left unsupervised while toileting. Surveyors observed the resident on the toilet without supervision and with no alarm in place, despite staff stating CNAs are expected to follow the care plan and not leave such residents unattended.
Failure to document and assess pain in a resident with aphasia, dementia, a prior femur fracture, and an indwelling catheter. Staff observed repeated restlessness, attempts to stand, and pulling at catheter tubing, while the wife reported possible catheter-related discomfort and difficulty interpreting the resident’s needs. Although the care plan and physician orders required pain assessment using a 0-10 or FACES scale and documentation of nonverbal indicators, the TAR and medical record did not show pain scores or a clear pain assessment, and an acetaminophen dose was given without a documented pain level or reason.
The facility failed to ensure a resident was offered pneumococcal immunization or that education and declination were documented. Record review showed the resident had no pneumococcal vaccine on file and was listed in WIR as recommended and overdue. The IP stated the facility no longer offers the vaccine, does not complete vaccine education, and refers residents to a clinic if they request it; the IP also acknowledged vaccination status was not being updated on admission or annually.
A resident with multiple chronic conditions and on hospice care was found without oxygen, resulting in low O2 saturation. The incident was not reported to the State Survey Agency within the required 24-hour period because staff initially did not consider it neglect. The delay in reporting was due to the acting administrator's inexperience and misjudgment of the situation.
A resident with multiple complex medical conditions received an anticoagulant medication after a physician had ordered it discontinued, due to a nurse following the resident's wishes rather than the physician's order. The facility did not report this medication error and alleged staff misconduct to the State Survey Agency within the required 24-hour period, citing administrative difficulties as the reason for the delay.
The facility's kitchen handwashing sink failed to maintain the required minimum water temperature, with the water reaching only 73°F after two minutes, below the required 100°F. This issue has persisted for several months since the sink replacement, as confirmed by the Culinary Staff Aide and Manager, who continued using the sink despite the deficiency.
The facility inaccurately reported staffing data to CMS, affecting all 31 residents. Errors in the PBJ system led to reports of no licensed nursing coverage on six days. Mistakes included unreported night shift hours, incorrect manual entries, and data entered into the wrong facility's system.
A CNA in an LTC facility failed to follow proper hand hygiene protocols while providing morning care to a resident. The CNA did not remove gloves, perform hand hygiene, or don clean gloves when transitioning from dirty to clean tasks, such as handling soiled briefs and personal care. The facility's hand hygiene policy was not adhered to, leading to a deficiency in infection prevention and control practices.
Infection Prevention and Control Program Deficiencies
Penalty
Summary
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. Survey review of infection control line lists from January 2025 through the present showed that the facility did not thoroughly document the onset of symptoms, the type of isolation used, when isolation was started, what tests were performed, or the well dates and outcomes for residents with respiratory symptoms. For one resident, the line list noted cold symptoms, cough, and later flu-like symptoms with sneezing, but the surveyor did not find documentation showing when or if isolation precautions were initiated, any testing for COVID, influenza, or RSV, or any documented well date or outcome. For another resident, the line list noted wheezing, congestion, low saturations, and a later hospital transfer with possible pneumonia, but the surveyor did not find documentation showing when or if isolation precautions were used, testing for influenza or RSV, or a well date. For a third resident, the line list noted sore throat, weakness, unsteady gait, scratchy voice, dry cough, and loose stools, but the surveyor did not find documentation showing when or if isolation precautions were initiated, testing for COVID, influenza, or RSV, or any documented well date. During interview, the Infection Preventionist stated the line list process had not been consistently documented in that fashion over the last year and acknowledged not knowing the facility needed to test for more than COVID for residents with respiratory symptoms. The Infection Preventionist also stated that not everyone with symptoms was tested for COVID and that the process had not been done consistently across the board. In addition, during a water pass observation, a CNA did not perform hand hygiene between resident rooms while handling contaminated and clean water pitchers for multiple residents. The surveyor also observed wound care for a resident with stage 3 buttock wounds where only gloves were worn, despite an Enhanced Barrier Precautions sign being present and the facility policy stating gowns and gloves were required for high-contact activities such as wound care.
Unsecured Medication Cabinets Outside Resident Rooms
Penalty
Summary
The facility did not ensure 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 the 100 unit and 200 unit. During the three-day survey, 6 of 26 observed medication cabinets outside residents’ rooms were left unlocked when unattended and out of view of staff, with prescribed medications stored inside. The facility policy, Medication Administration, revised August 2025, stated that only licensed nurses, med techs, the consultant pharmacist, and others lawfully authorized to administer medications were allowed access to medications, and that medication rooms, carts, and medication supplies were to be locked when unattended or attended only by authorized persons. Surveyors observed unlocked cabinets outside the rooms of six residents: one cabinet contained Trimacolone ointment labeled with the resident’s identifying information and dispersed on 04/14/24, along with a calcium alginate dressing; another contained an unknown white powder in a medicine cup; others contained arthritis cream, Difloneac cream, a prescription bottle of Hibiclens and an Aspercreme tube, and Equate arthritic cream with Trolamine Salicylate medication. During interview, an RN stated that if any prescribed medication was stored in the cabinets, all medication cabinets should be locked, and the RN attempted to lock one cabinet immediately. The NHA also stated that medication cabinets outside resident rooms should be locked if prescribed medications were in the cabinet and staff were out of sight.
Failure to Investigate and Resolve Grievance About Missing Necklace
Penalty
Summary
The facility failed to honor a resident’s right to voice grievances without discrimination or reprisal and did not establish prompt resolution of a grievance regarding a missing gold necklace. The facility policy required the Social Worker or designee to investigate complaints in a timely manner, keep a record of the investigation, develop a plan of action within 72 hours, interview all parties and witnesses, and provide updates and follow-up. Survey review of the grievance logs and an incomplete grievance complaint form showed a complaint dated 12/04/25 stating that R9’s gold necklace with “Sister” on it was missing, but the form did not contain a proper investigation or resolution process. During interview, Social Services J stated that grievances are typically documented on a grievance form and log, then investigated with interviews of the complainant and potential witnesses, with a narrative of the steps and outcome kept in a file. Social Services J reported being on maternity leave from 09/17/25 to 12/15/25 and was unsure what happened with R9’s grievance, stating that NHA A was to oversee grievances during that time. When interviewed, NHA A stated that the grievance was not followed up on and that it was a mistake.
Failure to Investigate Missing Resident Necklace
Penalty
Summary
The facility failed to ensure a resident was free of misappropriation and/or exploitation when it did not investigate or report an alleged missing item to the State of Wisconsin or local authorities after the resident first reported that a gold necklace was missing. The facility policy required timely investigation of complaints, immediate reporting of alleged misappropriation of resident property, and development of a plan of action within 72 hours of the social worker’s knowledge of the complaint. Survey review found an incomplete grievance complaint form attached to the grievance log stating that the resident’s gold necklace with a sister charm was missing, but there was no proper investigation or documented resolution for the missing item. During interview, Social Services reported that grievances are typically investigated, witnesses are interviewed, and outcomes are documented in a grievance file, but Social Services was on maternity leave during the relevant period and was unsure what happened with the grievance. The NHA stated that the grievance was not followed up on and that it was a mistake.
Inadequate monitoring of targeted behaviors for psychotropic medications
Penalty
Summary
The facility did not ensure that a resident was free from unnecessary drugs because it did not complete adequate monitoring of resident-specific targeted behaviors for psychotropic medication use. The deficiency involved R9, who was admitted with diagnoses including vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and major depressive disorder. R9 had physician orders for Buspirone 15 mg twice daily for depression/anxiety, Trazodone 50 mg daily for insomnia, and Paroxetine 20 mg and 40 mg daily combined to equal 60 mg for major depression and anxiety. R9’s care plan, initiated after admission and later revised, identified impaired cognitive function/Alzheimer’s dementia/vascular dementia and psychotropic drug use, but it did not include specific focus or interventions for targeted behaviors or monitoring for all three psychotropic medications. The facility policy required nursing staff to obtain an approved diagnosis and specific targeted behavior/indication for antipsychotic use and to monitor the specific behaviors for which the medication was prescribed. During survey review, the MDS/Interim DON was unable to find supporting documentation for behavior charting and monitoring related to the anti-anxiety and anti-depressant medications, and the NHA acknowledged the concern and stated targeted behaviors were to be added to the resident’s record.
Failure to Report Alleged Abuse, Injuries of Unknown Source, and Missing Property
Penalty
Summary
The facility did not ensure that alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property were reported timely to the State Agency or to law enforcement for three residents reviewed. The report states that the facility failed to report an injury of unknown origin for one resident, failed to report an injury of unknown origin for another resident, and failed to report the misappropriation of a resident’s personal property for a third resident. For one resident, staff discovered two skin tears to the right forearm after a CNA was assisting with care and the resident had reportedly been combative. The CNA stated there were no skin tears when leaving the room earlier, and the LPN found dried blood and the skin tears when assessing the resident. The facility initiated an alleged abuse investigation related to the CNA, but the initial incident report was not submitted within 2 hours to the State and was not submitted until two days later. Law enforcement was not contacted, and the NHA stated the facility did not call law enforcement because it could not prove abuse, while acknowledging that law enforcement should have been contacted due to the allegation. For another resident, records showed left ankle bruising, swelling, pain, and an acute nondisplaced distal fibular fracture after a transfer event. Nursing documentation noted the resident had complained of left ankle pain for the prior week and had swelling noted earlier, but the facility did not report the injury of unknown source to the State. For the third resident, grievance records showed a missing gold necklace, but the surveyor did not find a proper investigation, resolution, or reporting of the missing item. The NHA stated the grievance was not followed up on and that it was a mistake.
Incomplete Investigation of Injury of Unknown Origin and Missing Property Grievance
Penalty
Summary
The facility did not have evidence that all injuries of unknown origin and allegations of misappropriation of property were thoroughly investigated for two residents reviewed. One resident, with diagnoses including Alzheimer's disease, dementia with psychotic disturbance, and mild neurocognitive disorder, had a BIMS score of 7/15 indicating moderate cognitive impairment. During morning care, two CNAs discovered two skin tears to the resident's right forearm with dried blood on the blanket, and both CNAs denied knowing what caused the injuries. The LPN assessed the resident and provided first aid, but the accused CNA was allowed to remain on the unit and finish the shift, and the incident was later determined by the facility to possibly involve abuse or an injury of unknown origin. The investigation into the resident's skin tears was incomplete. The LPN questioned the two CNAs, but the accused CNA was not removed from the building, and the incident was not immediately reported to management. The DON was notified after arriving to work later that morning. The facility interviewed only two residents from the same unit who had severely impaired cognition and were not good historians, and the NHA later acknowledged that further interviews should have been conducted with residents with higher cognition on another unit because the CNA had worked both units. The facility also marked on its abuse checklist that contacting law enforcement was not applicable, despite the incident being considered possibly abuse or an injury of unknown origin. The facility also failed to thoroughly investigate a grievance involving a resident's missing gold necklace with a sister's name on it. The grievance log contained an incomplete complaint form, but surveyors did not find a proper investigation or resolution for the missing item. Social Services reported that grievances are normally investigated, documented, and followed through to resolution, but the Social Services staff member was on maternity leave during the relevant period and was unsure what happened with the grievance. The NHA stated that the grievance was not followed up on and that it was a mistake.
Failure to Implement Torticollis Orthosis Care Plan
Penalty
Summary
The facility did not implement the comprehensive care plan for a resident with Alzheimer's disease with late onset, moyamoya disease, left-sided hemiplegia and hemiparesis following cerebral infarction, epilepsy, dysphagia, aphasia, and moderate cognitive impairment. The resident's care plan, last revised 12/23/2025, directed staff to apply a torticollis orthosis during AM shift meals, place a padded area on the right side of the head, secure the strap around the back and under the arm, encourage the resident to relax the head back into a more upright position, and feed from the left side to improve positioning. The resident also had an activated POA for healthcare. During observations from 02/09/2026 through 02/11/2026, the resident was assisted with breakfast and lunch while seated in a Broda chair with the dining table to the right and staff feeding from the resident's right side, but the torticollis orthosis cushion was not in place during each observed meal. The cushion was observed lying on the desk in the resident's room, and signage on the closet door described its proper use. The resident stated the cushion was not being used during meals, that he could not feed himself, and that it was hard to swallow foods because of neck flexion to the right. A CNA stated the resident was supposed to wear the cushion but refused because he did not like it and said it hurt. OT and PT staff stated the cushion was intended for use during mealtime to assist with proper neck alignment, and both acknowledged the resident's compliance depended on which staff member applied it.
Care plan not revised for resident’s refusal and discomfort with torticollis orthosis
Penalty
Summary
The facility did not revise R16’s comprehensive care plan to reflect his preferences and needs related to the torticollis orthosis used for meal-time positioning. R16 was admitted with Alzheimer’s disease with late onset, moyamoya disease, hemiplegia and hemiparesis following cerebral infarction affecting the left nondominant side, epilepsy, dysphagia, and aphasia. His MDS assessment dated 12/30/2025 showed a BIMS score of 10/15, indicating moderate cognitive impairment, and he had an activated healthcare power of attorney. His care plan, last revised 12/23/2025, included applying the torticollis orthosis during AM shift meals and feeding from the left side to encourage improved positioning. During observations from 02/09/2026 through 02/11/2026, R16 was assisted with breakfast and lunch meals without the torticollis orthosis cushion in place. R16 told the surveyor that the cushion was not being used during meals and stated he did not like it because it hurt while in place. The cushion was observed on a desk in his room. CNA F stated R16 was supposed to wear it when eating but refused because it hurt him. RN D stated staff had tried it and that R16 did not like it because it hurt him. OT H stated the cushion was intended to be worn during mealtime to assist with proper neck alignment, and PT I stated R16’s compliance depended on the staff member applying it and that another PT evaluation for effectiveness was indicated. Record review showed the monthly restorative/maintenance summaries documented inconsistent participation with the torticollis orthosis, including 10/19 AMs in January and 0/30 AMs in February. CNA documentation showed refusals on multiple days, but not for all days in January and February. The care plan did not include R16’s resistance to wearing the orthosis, interventions to promote compliance when he experienced discomfort, or alternatives for maintaining neck alignment during meals. The TAR did not include documentation for monitoring placement of the cushion, and there were no orders for a PT reevaluation for placement and/or effectiveness of the torticollis orthosis cushion. MDS Coordinator/Interim DON B stated any nurse could make care plan changes and that care plans were reviewed quarterly and as needed, and was aware that R16 did not always wear the cushion.
Failure to Follow Repositioning Care Plan
Penalty
Summary
The facility did not ensure care was provided in accordance with the resident’s comprehensive person-centered care plan for one resident, R2. R2 was admitted to the facility and had a BIMS score of 99, indicating inability to complete the interview. R2’s care plan identified a potential for pressure ulcer development related to immobility and directed staff to assist with shifting weight in the wheelchair every 15 minutes and to remind or assist with turning and repositioning at least every 2 hours. During observation, R2 was taken to the dining room for breakfast in a Broda chair and remained there from 7:03 AM until 9:18 AM without being repositioned or having weight shifted every 15 minutes as directed by the care plan. R2 stayed in the Broda chair in the dining room in front of the television during that time. Interviews with CNA staff, the RN, the MDS/DON, and the NHA confirmed that care plans were available to staff, were expected to be followed, and were updated as changes occurred.
Failure to Supervise a Fall-Risk Resident During Toileting
Penalty
Summary
The facility did not ensure adequate supervision and assistance devices were provided to prevent accidents for one resident who was identified as a fall risk. The resident was cognitively intact with a BIMS score of 15/15 and had a history of multiple falls, including a fall from the toilet, a fall while trying to self-transfer from a recliner to the bathroom, a fall from the recliner, and a fall after sliding out of a wheelchair. The resident’s care plan included interventions to use a doorbell motion alarm in the bathroom and to not leave the resident unsupervised while toileting, and the fall risk interventions also included not leaving a high-risk resident unattended when toileting. Despite these documented interventions, the resident was observed on the toilet unsupervised with no alarms in place. Facility staff interviews showed that CNAs understood residents with toileting restrictions or alarms should not be left unattended in the bathroom, and the NHA stated CNAs should follow care plans and be monitored by floor nurses. The record review showed the resident had prior falls and that interventions were added after the first fall, but no new interventions or revisions were made for the most recent three falls.
Failure to Document and Assess Pain in a Nonverbal Resident
Penalty
Summary
Provide safe, appropriate pain management for a resident who required such services. The facility did not ensure pain management was consistent with the comprehensive assessment and plan of care for one resident, R5, who had aphasia following a cerebral infarction, vascular dementia with behavioral disturbance, restless leg syndrome, insomnia, repeated falls, urinary retention, and a history of a left femur fracture sustained after a fall at the facility. R5 also had an indwelling urinary catheter for chronic urinary retention and a BIMS score of 8/15, indicating moderate cognitive impairment. The care plan and physician orders directed staff to assess pain using a 0-10 scale or FACES scale and to document nonverbal indicators of discomfort, but the record did not show pain levels documented on the TAR or in the medical record. Survey observations and interviews showed R5 was frequently restless, attempted to stand from the wheelchair and bed, and repeatedly pulled at catheter tubing, at times dislodging the catheter. Staff and R5's wife described that R5 was difficult to understand because of the stroke and did not clearly verbalize needs. The wife stated she believed the catheter caused discomfort and that R5 may have pain around the penis because of pulling on the catheter. RN staff also stated R5 was up most nights and repeatedly attempted to exit the bed, but the cause of the restlessness was unclear. The facility documentation included notes about restless behaviors and catheter pulling, but no pain assessment was found in the record for those behaviors. The record also showed physician orders on 09/09/2025 to ask about pain or nonverbal indicators and document the appropriate number, and a later order for acetaminophen for chronic pain that was discontinued on 01/30/2026. The January and February 2026 TARs indicated pain assessments were done twice daily, but they did not include times or pain scores, only check marks and initials. Nursing documentation noted the Foley catheter caused discomfort and that the resident frequently tried to pull it out, and one MAR entry showed acetaminophen was administered without documenting a pain level or reason. When interviewed, the MDS coordinator/DON stated nonverbal residents are assessed for pain using the FACES scale and documented with the number conversion in the medical record.
Failure to Offer and Document Pneumococcal Vaccination
Penalty
Summary
The facility did not have a comprehensive system for ensuring residents received or were offered pneumococcal immunizations for 1 of 5 sampled residents, R6. Record review showed R6 had no pneumococcal vaccination on record, and the Wisconsin Immunization Registry listed the vaccine as recommended and overdue. The facility also had no documentation that R6 was offered the pneumococcal vaccine, educated on the risks and benefits of the vaccine, or that R6 declined the vaccination. During interview, the Infection Preventionist stated the facility no longer offers pneumococcal vaccinations and does not complete education about the vaccine. The Infection Preventionist reported that residents who want the pneumococcal vaccine are referred to a clinic, and acknowledged that the facility was not asking or updating vaccination status on admission or annually. The Infection Preventionist also stated there were no declinations for R6 because the vaccine had not been offered to R6.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the State Survey Agency within the required 24-hour timeframe. On 09/23/25, a resident with chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, pulmonary fibrosis, Alzheimer's disease, and on hospice care, was found without oxygen and diaphoretic, with an oxygen saturation of 71% on room air. Oxygen was reapplied, and the resident's saturation improved. The incident was initially not considered neglect by facility staff, and therefore was not reported as required by facility policy and federal regulations. Further review and discussion with the regional director led to the decision to report the incident in good faith, but this did not occur until 09/30/25, several days after the event. The delay was attributed to the acting administrator being new and not recognizing the situation as neglect at the time. The facility's policy requires all alleged violations involving abuse, neglect, exploitation, mistreatment, misappropriation of resident property, or injuries of unknown source to be reported to the State Survey Agency within 24 hours.
Failure to Timely Report Alleged Staff Misconduct to State Agency
Penalty
Summary
The facility failed to report an alleged violation involving mistreatment/misconduct within 24 hours to the State Survey Agency, as required by facility policy and federal regulations. Specifically, a registered nurse did not transcribe a physician's order to discontinue an anticoagulant medication and subsequently administered the medication without a valid physician order. The incident occurred on 07/17/25 and was discovered the following day, but the facility did not submit the initial report to the State Survey Agency until 07/24/25, well beyond the required 24-hour timeframe. The facility's policy mandates that all alleged violations involving abuse, neglect, exploitation, mistreatment, misappropriation of resident property, or injuries of unknown source be reported immediately to the Administrator and Director of Nursing, and to the State Survey Agency within 24 hours. The resident involved was admitted with multiple significant diagnoses, including congestive heart failure, chronic blood clots, anemia, ovarian and rectal cancer, and gastrointestinal bleeding. The resident was cognitively intact and required some assistance with mobility and toileting. The incident report indicated that the nurse administered the medication based on the resident's insistence, despite a physician's order to discontinue it, resulting in a medication error. The delay in reporting was attributed by the Nursing Home Administrator to concurrent issues and difficulty accessing the reporting system.
Inadequate Handwashing Sink Temperature in Kitchen
Penalty
Summary
The facility failed to maintain the handwashing sink in the kitchen at the required minimum water temperature, which is a deficiency in their food service operations. The water temperature at the handwashing sink was observed to be 73 degrees Fahrenheit after running for two minutes, which is below the required minimum of 100 degrees Fahrenheit as per the facility's policy and the FDA Food Code requirement of at least 85 degrees Fahrenheit. This issue has been ongoing for several months, as indicated by the Culinary Staff Aide and the Culinary Manager, who confirmed that the staff continued to use the sink for handwashing despite the inadequate water temperature. The deficiency was identified during a surveyor's visit to the kitchen, where the surveyor personally observed and measured the water temperature. The Culinary Staff Aide reported that the water temperature has been inconsistent since the sink was replaced earlier in the year, and due to time constraints, she could not wait for the water to warm up before washing her hands. The Culinary Manager acknowledged that the lukewarm water temperature was a known issue since the sink replacement, yet the staff continued to use it for handwashing, potentially affecting all residents in the facility.
Inaccurate Staffing Data Reporting to CMS
Penalty
Summary
The facility failed to ensure accurate reporting of mandatory staffing information to the Centers for Medicare and Medicaid Services (CMS) based on payroll data. This deficiency potentially affected all 31 residents residing in the facility. The facility's Payroll Based Journal (PBJ) system inaccurately reported that there was no licensed nursing coverage on six specific days within the fiscal quarter from April 1 to June 30, 2024. The infraction dates were identified as April 14, April 21, May 25, June 8, June 9, and June 23. Upon investigation, it was revealed that the errors were due to data entry mistakes. Specific issues included hours from the night shift not being reported, hours being manually entered on incorrect dates, and hours being entered into the wrong facility's PBJ system. For instance, 6.85 hours from the night shift of April 13 did not appear on the April 14 report, and 8 hours on June 8 and June 9 were mistakenly entered into another facility's system. Additionally, 7.25 hours worked by agency staff on the night shift were not carried over to the June 23 report.
Failure to Adhere to Hand Hygiene Protocols
Penalty
Summary
The facility staff failed to conduct proper hand hygiene while providing care to a resident, identified as R7, during a survey observation. Certified Nursing Assistant (CNA) C was observed assisting R7 with morning care, which included toileting, changing soiled briefs, and personal hygiene tasks. Despite the facility's hand hygiene policy, which mandates hand hygiene before and after resident contact, before putting on gloves, and after removing gloves, CNA C did not adhere to these guidelines. CNA C did not remove gloves, perform hand hygiene, or don clean gloves when transitioning from dirty tasks, such as handling soiled briefs, to clean tasks, such as applying lotion and dressing the resident. The surveyor noted multiple instances where CNA C failed to perform hand hygiene, including after handling soiled items and before assisting with personal care tasks like washing the resident's face and brushing dentures. CNA C acknowledged the oversight when questioned by the surveyor, recognizing the importance of hand hygiene for infection control. The Director of Nursing (DON) also confirmed the expectation for staff to follow proper hand hygiene practices to prevent infection transmission. The deficiency was identified as a failure to adhere to the facility's infection prevention and control program, specifically regarding hand hygiene practices.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Ladysmith
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Care & Rehab - Ladysmith 2 | 0 mi | ★★★★★ | 0 | 0 |
| Cornell Health Services | 21.2 mi | ★★★★★ | 0 | 0 |
| Meadowbrook At Chetek | 29.8 mi | ★★★★★ | 19 | 0 |
| Heritage Lakeside | 31.4 mi | ★★★★★ | 15 | 1 |
| Dove Healthcare - Rice Lake | 32.6 mi | ★★★★★ | 15 | 0 |
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