Care & Rehab - Ladysmith 1

In the surveyor’s words

From the most serious findings on record at Care & Rehab - Ladysmith 1, in the surveyor’s own words.

• Actual harm, isolatedF600Nov 11, 2021

  Based on record review and interview, the facility did not ensure that all residents were free from physical abuse and neglect for 1 of 4 residents (R1) reviewed for physical abuse. R1 sustained a subluxation of right thumb with bruising on right wrist during attempt by a licensed practical nurse and certified nursing assistant to obtain an oximetry reading. R1 sustained a bruise to the right forehead from R1's head hitting grab rail and sustained knee pain and a golf size bruise on the right knee, when a CNA neglected to get assistance for cares or use a 2 person assist for the hoyer lift transfer when R1 was agitated and combative. […]

• No harm, potential for more than minimal, widespreadF880Feb 24, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Nov 13, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF851Nov 13, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Oct 12, 2022

  Based on observation, interview and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect all residents in the facility. - Facility did not ensure foods were stored at safe ranges to prevent spoilage by not consistently checking refrigerator and freezer temperatures. -Facility did not ensure foods were cooked to safe temperatures, and held for serving at safe temperatures by not consistently checking food temperatures after cooking and prior to service. - Facility did not ensure dishes and cookware were properly sanitized by not consistently checking dishwasher temperatures and chemical sanitization levels in the three-compartment sink. […]