Care & Rehab - Ladysmith 2

In the surveyor’s words

From the most serious findings on record at Care & Rehab - Ladysmith 2, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Jan 12, 2022

  Based on observations, interviews, and record review, the facility did not establish and maintain an Infection Control Program designed to prevent the development and transmission of disease and infection, such as Covid-19, which has the potential to affect all 29 residents in the facility. Throughout the survey, observations were made in which staff did not wear appropriate Personal Protective Equipment (PPE) such as eye protection of goggles or face shields while in resident care areas, when the community transmission rate was high for Covid-19. […]

• No harm, potential for more than minimal, patternF880Feb 8, 2024

  Based on observations and interviews, the facility did not establish and implement an ongoing infection prevention and control program to prevent and control the onset and spread of infection as evidenced by the following observations. The facility did not ensure 12 of 16 residents (R) (R3, R6, R9, R12, R15, R16, R17, R18, R20, R23, R24, R25) were given the opportunity to conduct hand hygiene prior to meal services. The facility staff did not perform sanitization of durable medical equipment to prevent the spread of infection when warranted between resident transfers affecting 2 of 2 resident (R7 and R12). […]

• No harm, potential for more than minimal, isolatedF641May 5, 2026

  Based on record review and interview, the facility did not ensure to accurately code the Minimum Data Set (MDS) assessments for 1 of 1 resident (R) reviewed. (R1) R1's comprehensive MDS assessment indicated a PASARR level 2 screen had not been completed. R1's medical record included a PASARR screen was completed on 2/17/25. This is evidenced by: On 05/05/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including depression, post-traumatic stress disorder, dementia with anxiety, adjustment disorder, anxiety disorder, and other psychotic disorders.Annual MDS (Minimum Data Set) dated 12/30/25 documented section A1500 as No for currently considered by the state level II PASRR process to have serious mental illness and/or intellectual… […]

• No harm, potential for more than minimal, isolatedF689Mar 6, 2025

  Based on observation, record review and interview the facility did not provided the needed services and assistive devices. The facility practice had the potential to affect 1 of 5 residents (R) (R17) observed for transfer and ambulation This is evidenced by: Surveyor reviewed the facility policy titled Gait belts dated 7/24. The policy in part read: Policy: A gait belt provides a firm, grasping surface for the caregiver, protects the resident from accidental trauma to the skin, provides a sense of security to the resident, and protects the caregiver and resident from injury while transferring or ambulating. Suveyor reviewed the facility policy titled Fall Risk Management Policy dated 11/24. […]

• No harm, potential for more than minimal, isolatedF812Mar 6, 2025

  Based on random observation, record review and interview, the facility did not distribute foods in a sanitary manner. The facility practice affected one of one resident's (R) tray line service observed, (R17). This is evidenced by: Surveyor requested and reviewed the facility policy titled Food Handling Techniques For All Staff. which is not dated. The policy in part read: 1. What foods may not be touched with your bare hands? Answer: READY-TO-EAT FOODS Examples include: .Bread, toast, rolls, baked goods 2. What methods may be used to handle READY TO EAT FOODS? Answer: Utensils, tongs, napkins or disposable gloves. 3. Why is bare hand contact prohibited with READY-TO-EAT FOODS? Answer: Employees may transmit disease through unwashed or poorly washed hands. […]