Wausau Manor Health Services

Inspectors wroteBased on observation, 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, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials in accordance with State law through established procedures. The facility did not report a potential incident of neglect to the State Agency (SA) for 1 of 1 resident (R47) reviewed for reporting requirements. R47 requires 2 staff assistance with bed mobility and transfers. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure a thorough investigation was conducted for a potential incident of caregiver misconduct for 1 of 1 resident (R47) reviewed for investigating an alleged violation. The facility did not conduct a thorough investigation following R47's fall with injury. CNA D did not follow R47's plan of care, R47 fell and sustained an injury. The facility did not complete a thorough investigation into the incident and did not protect residents during the investigation.

Inspectors wroteBased on record review and interview, the facility did not accurately code the Minimum Data Set (MDS) assessments for 1 of 6 residents (R) reviewed. (R2)R2 had a Preadmission Screening and Resident Review (PASARR) 1 and 2 completed, which the MDS assessment did not reflect. This is evidenced by: R2 was admitted to the facility on [DATE]. R2's current diagnoses include dementia, post-traumatic stress disorder, anxiety disorder, and major depressive disorder. Review of R2's medical record found a PASARR level 2 screen was completed, dated 10/22/25. R2's annual MDS (Minimum Data Set) assessment, dated 11/10/25, documented Section A1500: Preadmission screening and resident review (PASRR) question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? The response selected was No. [...]

Inspectors wroteBased on interview and record review, the facility did not provide adequate supervision to prevent accidents for 1 of 3 residents (R47) reviewed for accidents. R47 requires assistance from two staff with bed mobility and transfers, per the plan of care. One certified nursing assistant (CNA) sat R47 on the edge of the bed and turned to retrieve the mechanical lift sling; during this time R47 fell from the bed landing on their face. R47 sustained significant bruising to their face.

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident who requires dialysis receives such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences for 1 of 1 sampled resident (R6) reviewed for dialysis. The facility failed to provide ongoing assessment of R6's condition and monitoring for complications before and after dialysis treatments. The facility did not have a system in place for accurate and ongoing communication with dialysis facility. The facility's policy titled Hemodialysis read in part, The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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]. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation and interview, the facility failed to dispose of garbage properly on 3 of 3 days of survey. Garbage was observed setting on the ground outside of the dumpsters and dumpster lids were observed to be open on 3 of 3 days of survey. This is evidenced by: Facility policy and procedure entitled Environment, last revised 9/2017, states in part: All trash will be contained in covered, leak-proof containers that prevent cross contamination. All trash will be properly disposed of in external receptacles (dumpsters) and the surrounding area will be free of debris. On 08/13/24 at 9:15 AM, Surveyor observed the 2 dumpsters; the lids were wide open and 2 bags of garbage were observed on the ground beside the dumpsters. On 08/14/24 at 8:22 AM, Surveyor observed a man inside the dumpster rearranging garbage bags. [...]