Wausau Manor Health Services

Based on observation, interview and record review, the facility did not maintain a safe and sanitary environment in which food is prepared and distributed. This has the potential to affect all 56 residents who reside in the facility.Facility staff did not conduct appropriate hand hygiene during food preparation and were observed touching ready to eat foods with contaminated gloved hands.This is evidenced by:The facility policy, titled Food Preparation, revised last 9/2017, states: All Foods are prepared in accordance with the FDA Food Code.1. All staff will practice proper hand washing techniques and glove use.The facility policy, titled Hand Washing- Food and Nutrition Services, revised last 8/16/22, states: Employees will wash hands as frequently as needed throughout the day using proper hand washing procedures1. When to wash:a. When entering the kitchen.g. During food preparation, as often as necessary to remove soil or contamination and to prevent cross contamination when changing task.i. Before donning disposable gloves for working with food and after gloves are removed.On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility did not ensure garbage and refuse were properly disposed in the outside garbage storage receptacles. This has the potential to affect all 33 residents residing in the facility.This is evidenced by:The facility policy titled, Environment, last revised 9/2017, states: .All trash will be contained in covered, leak-proof containers that prevent cross contamination.According to State Operations Manual, Appendix PP: Guidance to Surveyors for Long Term Care Facilities, revised last 4-25-25, garbage receptacles should be covered to prevent the harborage and feeding of pests.On 9/29/25 at 11:30 AM, Surveyor observed garbage dumpster uncovered, right side lid was open. On 9/29/25 at 2:30 PM, Surveyor observed garbage dumpster uncovered, right side lid was open. Surveyor observed for 15 minutes to make sure it wasn't being used.On 09/30/25 at 9:30 AM, Surveyor interviewed the Environment Services Manager (ESM) O who stated, Waste Management come early on Monday, Wednesday, and Friday to take garbage.On 9/30/25 at 2:54 PM, Surveyor and Dietary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections.Staff did not perform hand hygiene when changing gloves during resident cares and procedures for 4 of 12 residents (R). R31, R9, R5, R56Staff did not clean the mechanical lift in between patient use.Findings include:Facility policy and procedure titled, Hand Hygiene, dated 11/02/22, states in part: Hand Hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of antiseptic hand rub, also known as alcohol-based hand rub (ABHR).2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table.6. a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .The attached Hand Hygiene Table, dated 11/2/2022, states in part: Alcohol Based Hand Rub or Soap and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not develop a comprehensive person-centered care plan for the diagnosis of Congestive Heart Failure (CHF) with the use of a diuretic for 1 of 16 residents (R) R9 reviewed for care plans.This is evidenced by: The facility's policy, Comprehensive Care Plan read in part, The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. R9 was admitted to the facility on [DATE], with diagnoses including chronic diastolic congestive heart failure, hypertensive heart disease, and edema. R9's Minimum Data Set (MDS) assessment, confirmed a Brief Interview for Mental Status (BIMS) could not be completed. Staff assessment of R9's cognition showed R9 to have moderately impaired cognition. Review of R9's medical record identified orders for the following diagnosis of CHF:-Metolazone 5 mg tablet, give one tablet by mouth…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility did not include the participation of a resident or family representative at care planning conferences. This occurred for 3 of 4 residents, (R) R2, R9, and R48, reviewed for care conferences. The facility did not conduct and document care planning conferences for R2, R9, and R48. Findings: The facility policy, Comprehensive Care Plan read in part, The comprehensive care plan will be reviewed and revised as appropriate by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and as needed with changes in condition. The physician, other practitioner, or nurse designee will inform the resident and/or resident representative of the risks and benefits of proposed care, of treatment, and treatment alternatives/options. On 09/29/25 at 1:17 PM, Surveyor interviewed R9's activated Power of Attorney (POA). During the interview R9's POA reported concerns about R9 discharging to a different facility. R9's POA reported being unsure of what was going on or if R9 would be able to remain at the facility. On 09/30/25,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interview, the facility did not ensure a resident who was dependent for repositioning, personal cares, and hydration receive timely assistance for 1 out of 4 residents (R) (R5) reviewed for Activities of Daily Living. R5 who is dependent for hydration was not offered hydration during cares. R5 who is dependent for repositioning and turning was not repositioned for over 3 hours.This is evidenced by:The facility policy, titled Hydration, last revised 9/19/2024, states: The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. The facility policy, titled Turning and Repositioning, last revised 12/6/22, states: It is our policy to implement turning and repositioning as part of our systematic approach to pressure injury prevention and management. This policy establishes responsibilities and protocols for turning and repositioning. 2. Turning and repositioning is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, facility did not implement professional standards of practice to ensure that a resident does not develop pressure injuries (PIs), receives necessary treatment and services to promote healing and prevent new PIs from developing for 1 of 2 residents (R) reviewed. (R21) This is evidenced by:National Pressure Injury Advisory Panel (NPIAP) guidance recommends repositioning all individuals with or at risk of pressure injuries on an individualized schedule, unless contraindicated. Determine repositioning frequency with consideration to the individual's level of activity and ability to independently reposition. Reposition the individual in such a way that optimal offloading of all bony prominences and maximum redistribution of pressure is achieved.R21 was admitted to the facility on [DATE]. Current diagnoses include hypertensive heart and chronic kidney disease, weakness, cognitive communication deficit, type 1 diabetes mellitus, asthma, heart failure, chronic kidney…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility did not ensure pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 1 resident (R9). R9 had an order to check systolic blood pressure prior to administering medication, with parameters to hold the medication if systolic blood pressure was less that 110. The facility did not complete blood pressure checks as ordered. Findings include: The facility policy titled Medication Errors, read in part. Staff will follow best practices to prevent medication errors: a. Clarify an order that is incomplete. b. Ensure that orders are fully understood before administering medications.On 10/01/25, Surveyor reviewed R9's record and noted an order for: 01/02/25, metolazone 5 mg tablet every other day for possible heart failure exacerbation, hold for systolic blood pressure (SBP) <110. Surveyor was unable to find evidence of BPs prior to medication administration. Surveyor requested this from Director of Nursing (DON) B. On 10/01/25 at 9:21 AM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to provide privacy during wound care for one of three residents (R) 3, reviewed for wound care out of a total sample of 6 residents. This failure had the potential for R3 to experience embarrassment or feeling exposed during treatment. Findings include: Review of R3's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R3 was admitted to the facility on [DATE]. Review of R3's admission Evaluation - V3, located under the Assessments tab in the EMR and dated 08/14/25 at 6:44 PM, indicated R3 was alert and oriented to person, place, time, and situation. Review of R3's Physician Orders, located under the Orders tab in the EMR, indicated an order dated 08/19/25 for Left Buttock wound, Sacral redness, and Bilateral Buttock redness: Cleanse with NS [Normal Saline], pat dry, and apply Periguard Ointment every day and evening shift for wound healing and as needed for wound healing. During the wound care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and Centers for Disease Control and Prevention (CDC) guidance, the facility failed to follow infection control guidelines during a wound care observation for two of two residents resident (R), R2 and R3, observed for wound care and failed to follow Enhanced Barrier Precautions during a dressing change for R3. This failure had the potential for R2 and R3 to be exposed to infections. Findings include:Review of the CDC webpage titled, Clinical Safety: Hand Hygiene for Healthcare Workers, updated 02/27/24, revealed to change gloves and clean hands when moving from work on a soiled body site to a clean body site. Review of the CDC webpage titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), updated 04/02/24 revealed EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure activities of daily living and activities for dependent residents were completed per standards of practice and resident care plans for 2 out of 3 sampled residents (R) (R1 and R2). -R1 did not receive weekly showers. -R2 did not receive restorative care or weekly showers per standards of practice and the resident's care plan. This is evidenced by: Example 1 R1 was admitted on [DATE] with diagnoses that include post shoulder surgery, weakness, fragile X, fibromyalgia, morbid obesity, hemiplegia, and asthma. R1's brief interview of mental status (BIMS) score was 13/15 indicating intact cognition. Minimum Data Set (MDS) dated [DATE] indicates R1 is understood and understands. R1 is dependent on staff for showering, and received max assist with transfers, toileting, and bed mobility. On 07/07/25, Surveyor reviewed R1's record. In review of Certified Nursing Assistant (CNA) documentation for weekly showers, 2 out of 6 showers were not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility did not prepare, store and distribute foods in a safe and sanitary manner. The facility practices had the potential to affect all 48 residents. Initial tour of the facility kitchen found the floors in the kitchen, storage areas and dish room with food particles and built-up dirt present on the floors, the steamer and ovens with built up dried matter on the sides and bottom and on the industrial can opener mounted to the food preparation counter. Food temperatures were not taken at point of service in the rehabilitation kitchenette to ensure proper holding temperatures prior to serving food to residents. The food temperature logs were not complete. Dietary Aide (DA) D explained improper sanitization of thermometer procedures when temperatures are taken. This is evidenced by: Example 1 On 8/15/23 at 8:40 AM, Surveyor conducted an initial tour of the facility kitchen with Account Manager (AM) F who manages the dietary operations and has been on staff a few weeks. Surveyor noted the dry storage area floor, the kitchen floor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, staff did not perform hand hygiene to prevent the spread of infection when warranted while providing care to 1 of 4 residents (R) R28 observed for cares. Certified Nursing Assistant (CNA) C did not perform hand hygiene when warranted when providing incontinence care for R28. This is evidenced by: Example 1 Surveyor requested and reviewed the facility policy titled Hand Hygiene which is dated 11/02/22. The policy in part reads: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applies to all staff working within the facility. Hand Hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. ~After handling contaminated objects ~Before applying and after removing personal protective equipment, including gloves ~After handling items potentially contaminated with .body fluids On 8/16/23 at 10:43 AM, Surveyor observed CNA C assist R28 with care in the resdident's room. CNA C…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.